Universal Parameters for Reporting Speech Outcomes in Individuals with Cleft Palate

Influence of an Intensive Speech Therapy Program on the Speech of Individuals with Cleft Lip and Palate

Introduction  Compensatory articulations are speech disorders due to the attempt of the individual with cleft palate/velopharyngeal dysfunction to generate intraoral pressure to produce high-pressure consonants. Speech therapy is the indicated intervention for their correction, and an intensive speech therapy meets the facilitating conditions for the correction of glottal stop articulation, which is the most common compensatory articulation. Objective  To investigate the influence of an intensive speech therapy program (ISTP) to correct glottal stop articulation in the speech of individuals with cleft palate. Methods  Speech recordings of 37 operated cleft palate participants of both genders (mean age = 19 years old) were rated by 3 experienced speech/language pathologists. Their task was to rate the presence and absence of glottal stops in the 6 Brazilian Portuguese occlusive consonants (p, b, t, d, k, g) distributed within several places in 6 sentences. Results  Out of the 325 pretherapy target consonants rated with glottal stop, 197 (61%) remained with this error, and 128 (39%) no longer presented it. The comparison of the pre- and posttherapy results showed: a) a statical significance for the p1, p2, p3, p4, t1, k1, k2 and d6 consonants (McNemar test; p  < 0.05); b) a statistical significance for the p consonant in relation to the k, b, d, g consonants and for the t consonant in relation to the b, d, and g consonants (chi-squared test; p  < 0.05) in the comparison of the proportion improvement among the 6 occlusive consonants. Conclusion  The ISTP influenced the correction of glottal stops in the speech of individuals with cleft palate.

Compensatory Articulation Errors in Patients With Velopharyngeal Dysfunction and Palatal Anomalies

PURPOSE

The aim of this study was to assess the frequency and types of compensatory articulations (CAs) in nonsyndromic patients with velopharyngeal dysfunction (VPD) and various palatal anomalies and to determine the relationship between the frequency of CAs, type of palatal anomaly, and phonological errors.

METHOD

A total of 783 nonsyndromic, Hebrew-speaking patients with VPD and various palatal anomalies (cleft lip and palate [CLP], cleft palate [CP], submucous CP [SMCP], occult submucous CP [OSMCP], or non-CP) were studied retrospectively. Perceptual VPD tests, including articulation and phonological assessment, were conducted. CAs were described as below the level of the defect in the vocal tract (abnormal backing of oral targets to post-uvular place) or in front of it within the oral cavity (palatalization) and at the velopharyngeal port.

RESULTS

Among 783 patients, 213 (27.2%) had CAs. Most CAs (18.4%) occurred below the level of the defect, followed by CAs at the velopharyngeal port (12.0%) or in front of it (4.9%). No differences were found in the frequency of CAs between patients with CP (47.8%) or CLP (52.6%) and between those with non-CP (13.6%) or OSMCP (14.7%). SMCP patients had lower frequency of CAs (29.8%) than CP (p = .003) and CLP (p =  .002) patients but higher frequency than OSMCP (p = .002) and non-CP (p =  .002) patients did. Among the 783 patients, 247 (31.5%) had phonological errors. A higher frequency of phonological errors was found in patients with CAs (55.4%) compared to those without (22.6%) and in all palatal anomaly groups except CLP (31.4% vs. 23.9%).

CONCLUSIONS

CAs in nonsyndromic patients with VPD remained relatively high in all age groups, up to adulthood. CAs are influenced by inadequate velar length following palatal repair, as well as by oral structural abnormalities, whereas poor muscle function due to OSMCP and/or abnormal size and/or shape of nasopharynx has less influence. Errors produced in front of the velopharyngeal port are influenced by the structural anomaly of CLP. This information may contribute to general phonetic and phonological theories and genetic investigations about CP anomalies.

Training speech pathology students in the perceptual evaluation of speech in patients with cleft palate: Reliability results and the students' perspective

INTRODUCTION

Listener training is necessary to achieve agreement between perceptual ratings. However, evidence is limited regarding the effect of a training in the perceptual evaluation of cleft palate speech on the reliability of students in speech pathology. The aim of this study was to evaluate the short-term and longer-term effect of a training using the Belgian Dutch outcome tool for cleft palate speech on reliability and the students' experiences.

METHODS

A 2-h training was provided during a specialist course for 31 first year master students in speech pathology. Information regarding listener characteristics, speech documentation and speech analysis (speech parameters and rating scales) was discussed. This last part focused on the Belgian Dutch outcome tool for speech in patients with cleft palate, including reference samples and consensus listening exercises. Pre training (T1) and post-training reliability (immediately following the training (T2) and one month later (T3)) were collected for the speech variables speech understandability, speech acceptability, hypernasality, hyponasality, nasal emission and nasal turbulence that were rated by means of ordinal scales. Inter-rater reliability was determined with interclass correlation coefficients whereas percentages of agreement were calculated for the intra-rater reliability.

RESULTS

Qualitative inter-rater ICC categories improved for hyponasality and speech acceptability at T2 and T3, whereas the inter-rater reliability of the other variables remained stable regarding their interpreted categories. All ICC values quantitatively improved at T2, except hypernasality and nasal emission. At T3, three of those variables showed a small drop one month later. Regarding intra-rater reliability, a significant decrease for hypernasality and nasal turbulence was found at T2, whereas a significant increase was observed for nasal turbulence and speech acceptability at T3. All variables, except hypernasality, had improved intra-rater reliability at T3 in comparison with T1. Students experienced fewer difficulties with most variables after training. Evaluation of nasal emission and nasal turbulence remained however difficult and required, in the students' opinion, more attention.

DISCUSSION & CONCLUSION

Overall a positive training effect was noted, especially regarding the inter-rater reliability and the students' confidence in perceptual ratings. However, it remains a challenge to achieve a positive training effect for all target variables that is maintained over-time.

Speech Outcomes of Treatment for Velopharyngeal Insufficiency: Combined Use of an Overlapping Intravelar Veloplasty and Dynamic Sphincter Pharyngoplasty

BACKGROUND

Velopharyngeal insufficiency involving a large velopharyngeal gap and poor lateral wall movement is referred to as a "black hole" and remains a challenging problem for cleft surgeons. The effect of the pharyngeal flap on this form of velopharyngeal insufficiency is still debatable because a wide pharyngeal flap is associated with a high incidence of airway obstruction. The present study aimed to evaluate the speech outcomes of combined overlapping intravelar veloplasty and dynamic sphincter pharyngoplasty for the treatment of velopharyngeal insufficiency.

METHODS

Between March 2016 and June 2019, 15 patients with velopharyngeal insufficiency were treated with a combination of overlapping intravelar veloplasty and dynamic sphincter pharyngoplasty. Preoperative speech evaluation was performed on the basis of perceptual speech evaluation, nasometry, and nasoendoscopy. Postoperative speech evaluation using the same approach as that used preoperatively was performed after completion of speech therapy.

RESULTS

All 15 patients achieved satisfactory velopharyngeal port closure and speech phonation after completion of speech therapy. No additional procedures were performed to improve velopharyngeal port closure and speech production. The preoperative and postoperative results of perceptual speech evaluation, nasometry, and nasoendoscopy evaluation were significantly different (P < 0.01).

CONCLUSION

Combined treatment with overlapping intravelar veloplasty and dynamic sphincter pharyngoplasty can correct the velopharyngeal insufficiency "black hole" with highly reliable results and minimal risk of airway obstruction.

Normative nasalance scores in Chilean adults

PURPOSE

The present study is aimed towards determining and comparing normative nasalance scores in Chilean Spanish-speaking adult men and women.

METHODS

40 women (age range 18 to 35, X = 25.79, SD = 5.83) and 36 men (age range 18 to 35, X = 26.45, SD = 4.08) were invited to participate, all of them without any previous speech therapy, neurological pathologies, intellectual deficits, hearing loss, syndromes, or other diagnosed pathologies that could impact speech production.A study of proper velopharyngeal function was performed, using a perceptual resonance evaluation. Nasalance was determined using a model 6450 Nasometer, during the reading of three standardized speech samples in Spanish: a nasal passage (NP), an oronasal passage (ONP), and an oral passage (OP). Also, the nasalance distance was calculated. Genders were compared using Wilcoxon tests for independent samples.

RESULTS

The NP presented the highest percentage of nasalance, with 52.13% (± 4.73), followed by the ONP with 25.38% (± 3.7), and finally the OP, which presented the lowest value of 14.15% (± 5.03). Meanwhile, nasalance distance was 37.98% (± 5.32). Finally, no significant differences were observed when comparing the nasalance between genders (p >0.05).

CONCLUSION

The nasalance values obtained were similar to those observed for other Spanish speakers. Also, male and women showed similar scores. The results of this study are a contribution to the indirect assessment of velopharyngeal function in Chilean adults.

Comprehensive evaluation of velopharyngeal function in myasthenia gravis patients

PURPOSE

Hypernasality, which is a symptom of dysarthria, may be seen in patients with Myasthenia Gravis with bulbar symptoms. However, there is not enough evidence to show that these patients may have velopharyngeal dysfunction. This study investigates the features of velopharyngeal function in myasthenia gravis patients using objective and subjective measurement tools.

METHODS

Ten adult myasthenia gravis patients with bulbar symptoms and ten adult myasthenia gravis patients without bulbar symptoms were recruited for this study. Ten healthy subjects were also included as the control group. The nasalance scores of the participants were determined using a nasometer. The degree and pattern of velopharyngeal closure were scored using flexible nasoendoscopy during speech, blowing, dry swallowing, and food swallowing. Perceptual hypernasality was assessed.

RESULTS

Velopharyngeal dysfunction was detected in 50% of the myasthenia gravis patients with bulbar symptoms. Velopharyngeal dysfunction was not seen in myasthenia gravis patients without bulbar symptoms. The degree of velopharyngeal closure in patients with bulbar symptoms differed depending on the tasks being performed. No significant difference in velopharyngeal closure patterns was observed between the groups (p < 0.05).

CONCLUSION

Myasthenia gravis patients with bulbar involvement may have velopharyngeal dysfunction. It is important to conduct a comprehensive evaluation to assess all aspects of the velopharyngeal function.

The Feasibility of Cross-Linguistic Speech Evaluation in the Care of International Cleft Palate Patients

ABSTRACT

Many patients with cleft palate in developing countries never receive postoperative speech assessment or therapy. The use of audiovisual recordings could improve access to post-repair speech care. The present study evaluated whether English-speaking speech-language pathologists (SLPs) could assess cleft palate patients speaking an unfamiliar language (Tamil) using recorded media. Recordings obtained from Tamil-speaking participants were rated by 1 Tamil-speaking SLP and 3 English-speaking SLPs. Ratings were analyzed for inter-rater reliability and scored for percent correct. Accuracy of the English SLPs was compared with independent t tests and Analysis of Variance. Sixteen participants (mean age 14.5 years, standard deviation [SD] 7.4 years; mean age of surgery of 2.7 years, SD 3.7 years; time since surgery: 10.8 years, SD 5.7 years) were evaluated. Across the 4 SLPs, 5 speech elements were found to have moderate agreement, and the mean kappa was 0.145 (slight agreement). Amongst the English-speaking SLPs, 10 speech elements were found to have substantial or moderate agreement, and the mean kappa was 0.333 (fair agreement). Speech measures with the highest inter-rater reliability were hypernasality and consonant production errors. The average percent correct of the English SLPs was 60.7% (SD 20.2%). English SLPs were more accurate if the participant was female, under eighteen, bilingual, or had speech therapy. The results demonstrate that English SLPs without training in a specific language (Tamil) have limited potential to assess speech elements accurately. This research could guide training interventions to augment the ability of SLPs to conduct cross-linguistic evaluations and improve international cleft care by global health teams.

Effects of different calibration schedules on the test-retest differences of nasalance scores obtained with the Nasometer 6450

Nasometry is used to assess nasality in speech but it is unclear whether overly frequent recalibration of the instrument adds measurement errors. The goal of the present research study was to describe the effect of the Nasometer 6450 calibration on the nasalance scores of repeated recordings. In a first experiment, the Nasometer calibration values stored in the computer's registry were manipulated to investigate the impact on nasalance scores. In the second experiment, a set of pre-recorded speech samples was re-recorded 40 times with a Nasometer 6450 in 4 different calibration regimens: Short-term repeated recordings without (R1) and with recalibration (R2C), and long-term repeated recordings over 10 days without (R3) and with recalibration (R4C). The first experiment showed that, compared to a calibration value of 1.0, a value of 0.9 resulted in nasalance scores that were on average 3 points lower while a calibration value of 1.1 resulted in scores that were 0.5 points higher. The results of the second experiment showed test-retest differences of less than 2 nasalance points for 91% of the data for a non-nasal stimulus. For a nasal stimulus, 91% of data were within 5 points for R3 and R4C. The results suggested that frequent recalibration of the Nasometer may slightly increase test-retest differences of nasalance scores. An alternative procedure for verifying microphone balance without recalibration is suggested.

Better speech outcomes after very early palatal repair?-A longitudinal case-control study in Ugandan children with cleft palate

INTRODUCTION

Children born with cleft palate with or without cleft lip (CP±L) tend to use less oral pressure consonants and more glottal sounds in their babbling. The purpose of very early palatal repair (i.e., one-stage palatal closure prior to 6 months of age) is to make the palate functional before the onset of speech acquisition to reduce the anchoring of wrong patterns in the child's developing phonological system. As a result, less compensatory articulation errors are expected to be present. Currently, no detailed longitudinal speech outcomes after very early palatal closure are available. This study aimed to provide longitudinal speech outcomes in Ugandan children with CP±L who received palatal closure prior to the age of 6 months.

METHODS

Ten children with CP±L were assessed at a mean age of 5 and 10 years old. Speech understandability, speech acceptability, resonance, nasal airflow and articulation were perceptually rated by two experienced speech-language pathologists. Velopharyngeal function was estimated using the velopharyngeal composite score (VPC-sum). Information regarding speech therapy, fistula rate, and secondary (speech) surgery was collected. The outcomes were compared with the longitudinal outcomes of an age- and gender-matched control group of 10 Ugandan children without CP±L.

RESULTS

Speech understandability and acceptability improved significantly over time in the group with CP±L (all p's ≤ 0.05, all Z's > -2.43). At both test dates, significantly worse judgments were found for the group with CP±L compared to the control group for these variables and variables related to passive speech errors (all p's ≤ 0.05, all Z's > 2.49). A statistically significant difference with the control group was found for the presence of compensatory articulation errors at the age of 5 years but not at the age of 10 years, indicating a catch up by the children with CP±L.

CONCLUSION

Whether a one-stage palatal closure prior to the age of 6 months is more favorable for speech outcomes compared to one-stage palatal closure at 12 months is still not clear. Speech of the children with CP±L improved over time, but significantly differed from the control group at the age of 5 and 10 years old. Limited access to health care facilities and possible influence of malnutrition on wound healing need to be considered when interpreting the results. Whether palatal closure prior to the age of 6 months is transferable to other countries is subject for further research, including both longitudinal and prospective designs with larger samples.

Subjective and Objective Evaluation of Speech in Adult Patients with Unrepaired Cleft Palate

OBJECTIVE

To explore the speech outcomes of adult patients through subjective perception evaluation and objective acoustic analysis, and to compare the differences in pronunciation characteristics between speakers with adult patients with unrepaired cleft palate and their non-cleft peers.

PARTICIPANTS AND INTERVENTION

Subjective evaluation indicators included speech intelligibility, nasality, and consonant missing rate, whereas objective acoustic parameters included normalized vowel formants, voice onset time, and the analysis of three-dimensional spectrogram and spectrum, were carried out on speech samples produced by 2 groups of speakers: (a) speakers with unrepaired cleft palate (n = 65, mean age = 25.1 years) and (b) typical speakers (n = 30, mean age = 23.7 years).

RESULTS

Compared with typical speakers, individuals with unrepaired cleft palate exhibited a lower speech intelligibility with higher nasality and consonant missing rate, the missing rate is highest for the 6 consonants syllables. The acoustic parameters are mainly manifested as differences in vowel formants and voice onset time.

CONCLUSIONS

The results revealed important acoustical differences between adult patients with unrepaired cleft palate and typical speakers. The trend of spectral deviation may have contributed to the difficulty in producing pressure vowels and aspirated consonants in individuals with speech disorders related to cleft palate.

One Size Doesn't Fit All: A Pilot Study Toward Performance-Specific Speech Intervention in Children With a Cleft (Lip and) Palate

PURPOSE

Speech-language pathologists usually apply a "one size fits all" approach to eliminate compensatory cleft speech characteristics (CSCs). It is necessary to investigate what intervention works best for a particular patient. This pilot study compared the effectiveness of two therapy approaches (a motor-phonetic approach and a linguistic-phonological approach) on different subtypes of compensatory CSCs in Dutch-speaking children with a cleft (lip and) palate (CP ± L).

METHOD

Fourteen children with a CP ± L (M _age = 7.71 years) were divided into two groups using block randomization stratified by age, gender, and type of compensatory CSC. Six children received intervention to eliminate anterior oral CSCs (n = 3 motor-phonetic intervention, n = 3 linguistic-phonological intervention). Eight children received intervention to eliminate non-oral CSCs (n = 4 motor-phonetic intervention, n = 4 linguistic-phonological intervention). Each child received 10 hr of speech intervention divided over 2 weeks. Perceptual and psychosocial outcome measures were used to determine intervention effects.

RESULTS

Children who received linguistic-phonological intervention to eliminate anterior oral CSCs had significantly higher correctly produced consonant scores and health-related quality of life (HRQoL) scores compared to children who received motor-phonetic intervention to eliminate anterior oral CSCs. In the group of children who received intervention to eliminate non-oral CSCs, no significant differences were found in the correctly produced consonant scores nor in the HRQoL scores between the two intervention approaches.

CONCLUSIONS

Linguistic-phonological intervention seems to be more appropriate to eliminate anterior oral CSCs. The beneficial effects of linguistic-phonological intervention were less pronounced in children with non-oral CSCs. Perhaps, children with non-oral CSCs benefit more from a hybrid phonetic-phonological approach. This study is a step forward in the provision of performance-specific intervention in children with a CP ± L. Replication in larger samples is needed and will aid to tailor treatment plans to the needs of our patients.

Correlation of the Chinese velopharyngeal insufficiency-related quality of life instrument and speech in subjects with cleft palate

OBJECTIVE

Assessment of the hypothesized correlation between the Chinese Velopharyngeal Insufficiency (VPI) Effects on Life Outcomes (VELO) instrument and measured speech parameters.

METHODS

A cross-sectional study was conducted in the Oral Clefts Center of West China Hospital of Stomatology between January 2019 and December 2019. Speech parameters including speech intelligibility deficit, VPI severity, VP gap, and need for speech therapy were evaluated by speech-language pathologists. All patients and their parents completed the VELO instrument. The correlation between aforementioned speech parameters and VELO scores was examined utilizing Spearman correlation coefficients. The reliability of VELO test-retest and parent proxy assessment was estimated utilizing intraclass correlation coefficients (ICC). A receiver operating characteristic curve was used to calculate the cutoff VELO score.

RESULTS

One hundred and forty patients with their parents were enrolled. The mean age was 12.58 ± 3.72 years. Both parent and youth VELO total and domain scores recorded moderate to strong correlations with all speech parameters (r > -.40, P ˂ .001) except the swallowing domain. Most VELO domain items have shown significant correlations with at least one speech parameter. Moreover, the scales of all speech parameters showed different VELO scores (P ˂ .001). The ICC reported test-retest correlation >.73 in all domains, and parent proxy correlation >.63 in most domains except the emotional and perception domains. The cutoff VELO score was 79.04 in parent version and 85.77 in youth version.

CONCLUSIONS

The correlations between VELO scores and measured speech parameters have provided evidence for test-retest and parent proxy reliability and criterion and construct validity of the Chinese version of the VELO instrument. A VELO score ≥79.04 (in parent version) or ≥85.77 (in youth version) mostly reflects proper speech-related quality of life. Hence, this instrument could serve as a simple tool to help clinicians understand the social, emotional, and physical influences of VPI.

Speech diagnosis and intervention in children with a repaired cleft palate: A qualitative study of Flemish private community speech-language pathologists' practices

Purpose: This study investigated the practice patterns of private community speech-language pathologists (SLPs) when treating children with a repaired cleft of the palate with or without a cleft of the lip (CP ± L). Practices were explored in terms of diagnostics and treatment focus, treatment dosage and experienced difficulties when treating children with a CP ± L.Method: Eleven female private community SLPs, who lived in Flanders (i.e. the northern part of Belgium) and were aged between 23 and 62 years participated in this study. Data were collected from semi-structured face-to-face interviews. The qualitative software program NVivo 12 was used for data analysis. The interviews were analysed using an inductive thematic approach.Result: SLPs reported a lack of available information on speech-related cleft care. SLPs expressed the need to receive a referral letter from the hospital in order to make an adequate speech diagnosis. Most therapists reported that they performed an articulatory assessment combined with a language assessment. Most SLPs used a hybrid treatment model including a variety of intervention techniques. These techniques were not always in line with available scientific evidence. SLPs reported the desire to receive practical step-by-step guidelines on how to provide speech intervention to children with a CP ± L. In contrast, there was a strong consensus among the therapists that an individualised treatment plan is necessary.Conclusion: The results of this study have revealed gaps in the dissemination and implementation of scientific evidence relevant to speech services for children with a CP ± L (i.e. a research-practice gap) in Flanders. Research evidence needs to be adequately translated into clinical practice by providing concrete and practical guidelines.

A systematic review of early speech interventions for children with cleft palate

BACKGROUND

Children with cleft palate with or without cleft lip (CP±L) are at high risk of problems with early speech sound production, and these difficulties can persist into later childhood. Early intervention could help to reduce the number of children whose problems become persistent. However, much research in the field to date has focused on older children. There is a need to determine if providing intervention during the phase of early typical speech development leads to better outcomes.

AIMS

To review the evidence for the effectiveness of interventions targeting speech, delivered in the first 3 years of life for children with CP±L, and discuss factors such as intervention type, facilitator, dosage, outcome measures and the age of the child.

METHODS & PROCEDURES

The systematic review was registered with PROSPERO (CRD42019121964). Eight bibliographic databases including CINAHL and MEDLINE were searched in August 2018. Studies were included if participants received speech and language interventions before 37 months and if they reported outcomes for speech. Two reviewers independently completed inclusion reviews, quality analysis and data extraction.

OUTCOME & RESULTS

The review included seven papers: one pilot randomized controlled trial, one controlled trial, four cohort studies and one case series report. Interventions largely took a naturalistic approach, namely focused stimulation and milieu teaching. The findings provide preliminary support for naturalistic interventions and suggest that these interventions can be delivered by parents with suitable training. Studies included in the review provided low-strength evidence with variation in both the type of intervention, the manner of delivery and in the risk of bias in the designs used.

CONCLUSIONS & IMPLICATIONS

The papers included in this review suggest that early naturalistic interventions can have positive impacts on the speech development of children with CP±L. However, the reported methodological quality of the publications overall was weak, and the current evidence lacks clarity and specificity in terms of therapy technique, delivery and optimum age of delivery. Future research should use more robust methodological designs to determine whether early speech interventions are beneficial for children born with CP±L.

WHAT THIS PAPER ADDS

What is already known on the subject Children with CP±L show difficulties with early speech development and often have restricted speech sound inventories. They may reach the canonical babbling stage later than children without CP±L and studies have shown that 20% of children with CP±L have speech which is considered unintelligible or barely intelligible at age 5. It has been proposed that early intervention can lessen the impact of CP±L on speech development. However, currently, the evidence for early interventions for children with CP±L is limited, with the majority of studies focusing on children aged 3 years and older. What this paper adds to existing knowledge This paper reviews the evidence for different types of early interventions for speech provided to children born with CP±L and whether these interventions are effective in supporting speech sound development. In this review, early intervention is defined as intervention provided to children in the first 3 years of life. This review describes intervention approaches and how they are delivered for this population. What are the potential or actual clinical implications of this work? In the UK, children born with CP±L and their families are supported by National Health Service (NHS) services over a 20-year period and speech and language therapy sessions may take place over many weeks and months. If providing early intervention in the first 3 years of life is effective, there is the potential for improved speech outcomes in early childhood and a reduced burden of care on children, families and services. This review considers the evidence for early speech intervention for children with CP±L in the first 3 years of life and identifies areas for future research.

Speech Development in Cleft Palate with and without Robin Sequence

BACKGROUND

Robin sequence is defined as the triad of micrognathia, glossoptosis, and upper airway obstruction. In up to 85 percent, it is associated with cleft palate. Many studies have reported worse speech development in Robin sequence children after cleft palate repair. The authors investigated speech development in isolated Robin sequence with cleft palate versus children with cleft palate only at the age of 5 to 6 years.

METHODS

All Robin sequence children were treated with the Tübingen palatal plate after birth. Data were collected using the German version of the Great Ormond Street Speech Assessment. Audio and video recordings were reviewed and analyzed separately by two blinded senior phoniatricians based on the German version of the Universal Reporting Parameters for Cleft Palate Speech, and scored to enable comparability of speech outcomes.

RESULTS

Forty-four children (Robin sequence, n = 22; cleft palate only, n = 22) were included. Robin sequence children were significantly older at surgery (11.8 months versus 7.1 months; p < 0.001) but younger at study (70.5 months versus 75.2 months; p = 0.035). They also had more severe cleft of the palate (p = 0.006). All children studied showed good to very good speech development without serious impairment. None of the reported parameters on the German version of the Universal Reporting Parameters for Cleft Palate Speech showed significant group differences; the median total score in the Robin sequence group was 23 (interquartile range, 16.5 to 27.5) versus 19 (interquartile range, 17 to 23) in the cleft palate-only group. Statistical analysis revealed no significant effect of group (Z = -1.47; p = 0.14).

CONCLUSIONS

No group differences in speech development were found at age 5 to 6 years. Isolated Robin sequence does not necessarily represent a risk for impaired speech development.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Risk, III.

Phonological Profile of Patients With Velopharyngeal Dysfunction and Palatal Anomalies

PURPOSE

This purpose of this study was to assess the frequency and types of phonological process errors in patients with velopharyngeal dysfunction (VPD) and the different types of palatal anomalies.

METHOD

A total of 808 nonsyndromic patients with VPD, who underwent follow-up at the Center for Cleft Palate and Craniofacial Anomalies, from 2000 to 2016 were included. Patients were stratified into four age groups and five subphenotypes of palatal anomalies: cleft lip and palate (CLP), cleft palate (CP), submucous cleft palate (SMCP), occult submucous cleft palate (OSMCP), and non-CP. Phonological processes were compared among groups.

RESULTS

The 808 patients ranged in age from 3 to 29 years, and 439 (54.3%) were male. Overall, 262/808 patients (32.4%) had phonological process errors; 80 (59.7%) ages 3-4 years, 98 (40, 0%) ages 4.1-6 years, 48 (24.7%) 6.1-9 years, and 36 (15.3%) 9.1-29 years. Devoicing was the most prevalent phonological process error, found in 97 patients (12%), followed by cluster reduction in 82 (10.1%), fronting in 66 (8.2%), stopping in 45 (5.6%), final consonant deletion in 43 (5.3%), backing in 30 (3.7%), and syllable deletion and onset deletion in 13 (1.6%) patients. No differences were found in devoicing errors between palatal anomalies, even with increasing age. Phonological processes were found in 61/138 (44.20%) with CP, 46/118 (38.1%) with SMCP, 61/188 (32.4%) with non-CP, 70/268 (26.1%) with OSMCP, and 25/96 (26.2%) with CLP. Phonological process errors were most frequent with CP and least with OSMCP (p = .001).

CONCLUSIONS

Phonological process errors in nonsyndromic VPD patients remained relatively high in all age groups up to adulthood, regardless of the type of palatal anomaly. Our findings regarding the phonological skills of patients with palatal anomalies can help clarify the etiology of speech and sound disorders in VPD patients, and contribute to general phonetic and phonological studies.

Exploration of the Influences of Temporary Velum Paralysis on Auditory-Perceptual, Acoustic, and Tomographical Markers

Purpose To better understand hypernasality (HN), we explored the relations between velopharyngeal orifice, auditory perception of HN, and acoustic-spectral measures in an in vivo within-subject design: (a) with a normally functioning velum as the control condition and (b) with a temporarily paralyzed velum as the experimental condition. Method The velum of eight volunteers was injected with ropivacaine hydrochloride (Naropin) in the area of the levator veli palatini and tensor veli palatini muscles to induce temporary velopharyngeal inadequacy (VPI) and HN. Sustained [a] and [i] and oronasal text readings were recorded, and 3D cone-beam computed tomography images of the vocal tract were built before and during velar anesthesia. Differences between conditions and correlations in normal-to-numb differences between velopharyngeal cross-sectional area (VP_area), mean ratings of HN severity, and nine acoustic-spectral measures were determined. Results Three subjects already had some incomplete velopharyngeal closure in the control condition. Temporary motor nerve blockage of the velum (increased VP_area) was accomplished in seven subjects, leading to increased HN and changes in three acoustic-spectral measures. Furthermore, significant correlations only emerged between VP_area, HN, and Model_Kataoka. Conclusions In most of the participants, it was possible to temporarily increase the velopharyngeal orifice to investigate HN while controlling other speech variables and cephalic morphology. Although this study was exploratory and its are findings preliminary, it provided additional evidence for the possible clinical value of Model_Kataoka, A ₃-P ₀, and B _F1 for the objective measurement of VPI or HN.

Speech Outcomes of a National Cohort of Children with Orofacial Cleft at 5 and 10 Years of age

OBJECTIVE

To assess speech outcomes at five and ten years of age in a nationwide study of children with orofacial cleft.

DESIGN

Prospective study.

PARTICIPANTS

Children born with orofacial cleft and having primary surgery in New Zealand. Speech samples were available for 151 five-year-old, and 163 ten-year-old children.

MAIN OUTCOME MEASURES

Intelligibility, Acceptability, Velopharyngeal function, Hypernasality, Hyponasality, severity of airflow evaluated by perceptual speech assessment (using the standardised Rhinocleft assessment), and overall assessment of requirement for clinical intervention.

RESULTS

A large proportion of five-year-old children had speech that was considered to be not completely intelligible, was not acceptable, and had inadequate velopharyngeal function. The noted deficiencies led to a clinical judgement that further speech and/or surgical intervention was required in 85% with cleft lip and palate, 65% with cleft palate and 26% with cleft lip. The proportion of children with poor speech outcomes in the ten-year-old children was lower, though of clinical importance, further intervention required for 25% with CLP, 15% with CP and 3% with CL. The number of sound production errors in both age groups followed the same pattern with fewest in those with CL and most in those with CLP.

CONCLUSIONS

A significant proportion of children with orofacial cleft were found to have poor speech outcomes requiring further treatment. The outcomes are poor compared to centres reported in the UK and Scandinavia. New Zealand requires a review of the current services for individuals born with cleft to improve speech outcomes and interdisciplinary care.

Preoperative pharyngeal depth is associated with postoperative velopharyngeal function following primary cleft palate repair at the age of five and above

To determine prognostic factors for postoperative velopharyngeal function following the primary cleft palate repair at the age of five and above. This study reviewed patients with cleft palate who had undergone Furlow palatoplasty at age 5 or older from 2009 to 2014. We obtained intraoperative measurements, including velar length, pharyngeal depth, cleft width, maxillary width, cleft palate index (cleft width/maxillary width) and palatopharyngeal ratio (velar length/pharyngeal depth), as well as speech evaluation results at least 1 year after surgery. Logistic regression and retrospective analyses were performed to determine factors associated with speech performance after the primary cleft palate repair. Among the six intraoperative measurements of velopharyngeal morphology, only pharyngeal depth was incorporated into the regression model, and was found to have an inverse association with postoperative velopharyngeal function, Exp (B) 0.883 (95% CI 0.798-0.976). Moreover, a pharyngeal depth greater than 16 mm was significantly associated with a higher risk of postoperative velopharyngeal insufficiency (P < 0.01). Pharyngeal depth is potentially a prognostic indicator for the primary management of cleft palate in older patients. Pharyngoplasty may need to be considered when the pharyngeal depth is large and the patient's access to surgery is limited.

A Deep Learning Algorithm for Objective Assessment of Hypernasality in Children With Cleft Palate

OBJECTIVES

Evaluation of hypernasality requires extensive perceptual training by clinicians and extending this training on a large scale internationally is untenable; this compounds the health disparities that already exist among children with cleft. In this work, we present the objective hypernasality measure (OHM), a speech-based algorithm that automatically measures hypernasality in speech, and validate it relative to a group of trained clinicians.

METHODS

We trained a deep neural network (DNN) on approximately 100 hours of a publicly-available healthy speech corpus to detect the presence of nasal acoustic cues generated through the production of nasal consonants and nasalized phonemes in speech. Importantly, this model does not require any clinical data for training. The posterior probabilities of the deep learning model were aggregated at the sentence and speaker-levels to compute the OHM.

RESULTS

The results showed that the OHM was significantly correlated with perceptual hypernasality ratings from the Americleft database (r = 0.797, p < 0.001) and the New Mexico Cleft Palate Center (NMCPC) database (r = 0.713, p < 0.001). In addition, we evaluated the relationship between the OHM and articulation errors; the sensitivity of the OHM in detecting the presence of very mild hypernasality; and established the internal reliability of the metric. Further, the performance of the OHM was compared with a DNN regression algorithm directly trained on the hypernasal speech samples.

SIGNIFICANCE

The results indicate that the OHM is able to measure the severity of hypernasality on par with Americleft-trained clinicians on thisdataset.

Precision Pharyngeal Flap: An Individualized, Patient-Specific Surgery for the Treatment of Velopharyngeal Insufficiency

BACKGROUND

The pharyngeal flap is one of the most common secondary surgeries for the correction of velopharyngeal insufficiency (VPI) for patients with cleft palate and/or cleft lip and palate. This study aimed to demonstrate the effectiveness of the precision pharyngeal flap surgery performed by the senior author.

MATERIALS AND METHODS

Children with VPI, who underwent precision pharyngeal flap, were retrospectively examined. All surgical procedures were performed by the senior author. The flap size was individually configured based on the patients' preoperative nasopharyngoscopic analysis and speech function evaluation. Pre- and post-operative velopharyngeal functions were assessed using perceptual speech evaluation and nasometric analysis; factors affecting surgical outcomes were determined.

RESULTS

Of 138 patients, 112 (women: 53, men: 59) were included in analyses, according to the inclusion and exclusion criteria. The median follow-up period was 21 months (range: 9-120). Postoperative perceptual speech evaluation revealed improved velopharyngeal function in 108 (96.4%). There were no reports of postoperative hyponasality (preoperative, 1.8% versus postoperative, 0%; P = 0.053). Other parameters of perceptual speech evaluation (hypernasality, nasal emission, articulation error, and intelligibility) showed significant improvement postoperatively (P < 0.01). Postoperative nasalance scores revealed sufficient postoperative resonance rating in 96% of patients. No patients experienced postoperative complications (bleeding, airway obstruction, and surgical wound dehiscence).

CONCLUSIONS

Individually configured pharyngeal flaps designed based on preoperative nasopharyngoscopic examination coupled with precise surgical techniques led to the high surgery success rate for VPI treatment.

Is High-Intensity Speech Intervention Better? A Comparison of High-Intensity Intervention Versus Low-Intensity Intervention in Children With a Cleft Palate

Purpose The purpose of this study was to compare the effect of speech intervention provided with a low intensity with speech intervention provided with a high intensity on the speech and health-related quality of life (HRQoL) in Dutch-speaking children with a cleft palate with or without a cleft lip (CP ± L) between 4 and 12 years. Method A longitudinal, prospective, randomized controlled trial with a multiple baseline design was used. Twelve children with a CP ± L (M _age = 8.0 years, SD = 1.54) were divided into two groups using block randomization stratified by age and gender: One group received low-intensity speech intervention (LISI; n = 6) and one group received high-intensity speech intervention (HISI; n = 6). Children in the LISI group received intervention with a session duration of 1 hr, a dose frequency of 1 session per week, and a total intervention duration of 10 weeks. Children in the HISI group received intervention with a session duration of 1 hr, a dose frequency of 5 sessions per week, and a total intervention duration of 2 weeks. The cumulative intervention intensity was kept constant. Both groups received identical therapy programs provided by the same experienced speech therapist. Perceptual speech assessments were performed on baseline and posttreatment data points. Changes in HRQoL were assessed using the Velopharyngeal Insufficiency Effects on Life Outcomes (VELO) questionnaire. Both groups were compared over time using (generalized) linear mixed models. Results No significant Time × Group interactions were observed for the percentage of correctly produced consonants at the word and sentence levels, indicating no differences in evolution over time among the two groups. The variables speech understandability, speech acceptability, and the total VELO scores significantly improved following HISI, but not following LISI. Conclusions Children in the HISI group made equal and, for some variables, even superior progress in only 2 weeks of therapy compared to children in the LISI group who received 10 weeks of therapy. HISI is a promising strategy to improve speech outcomes and HRQoL in a shorter time period.

Autologous Fat Grafting in Velopharyngeal Insufficiency Gives Complete and Stable Speech Recovery in Patient Under 7 years

ABSTRACT

The authorspresent a retrospective observational cohort study of 47 French speaking consecutive patients treated with retropharyngeal wall filling with autologous fat graft from 2006 to 2019 in a single tertiary center, to assess with a long-term follow-up, the best tailored treatment to recovery speech for velopharyngeal insufficiency, and to stress the importance of early treatment with minimally invasive procedure with retropharyngeal wall fat grafting. In preoperative setting, a clinical and instrumental evaluation with aerophonoscope is completed by a palatal closure assessment with nasal endoscopy. All patients were classified according with Borel Maisonny score pre- and post-operatively. Sixty three fat injections were performed. In 4 cases a pharyngeal flap was performed after fat graft for an insufficient speech result. The authors had no complications. Patients with less than 7 years of age obtained a complete recovery of their velopharyngeal incompetence (P = 0.03) compared to older patients. In conclusion, the authors can state that this tailored surgical technique needs a multidisciplinary approach. Many variables can affect postoperative results: fat reabsorption, concurrently performed surgery, pattern of pharyngeal closure, hearing impairment. None of these factors affected our result. Early treatment plays a crucial role to achieve better results. Patients with less of 7 years showed a better result in this functional treatment.

Characteristics and surgical outcomes of cleft palate in kabuki syndrome: a case series of 11 patients

OBJECTIVE

A significant number of patients with KS have cleft palate (CP) or submucous cleft palate (SMCP) and show delayed speech development. However, few reports have discussed the characteristics of CP in KS and the outcomes of postoperative speech development. The purpose of this study was to investigate the characteristics and surgical outcomes of CP in patients with KS, and to discuss the importance of the diagnosis of CP or SMCP.

METHODS

We conducted a retrospective study on patients with clinically diagnosed KS who underwent palatoplasty. Clinical and surgical data were collected from patients' medical records, and velopharyngeal function was evaluated using nasopharyngoscopy and speech analysis.

RESULTS

In 11 cases, 5 patients had CP (45.5%) and 6 had SMCP (54.5%). Four patients who were genetically tested had a pathogenic variant of KMT2D. Seven of nine patients (77.8%) who underwent conventional palatoplasty showed velopharyngeal insufficiency and hypernasality. All patients who underwent pharyngeal flap surgery achieved velopharyngeal competency. Statistical analysis revealed a statistically significant difference in postoperative results between non-syndromic and KS patients.

CONCLUSION

Patients with SMCP may be more common than previously reported. The results showed that it is difficult to produce optimal results with conventional palatoplasty; therefore, pharyngeal flap surgery should be considered as a treatment to obtain favorable results. Pharyngeal flap surgery in patients with KS should be carefully designed based on speech evaluation and nasopharyngoscopic findings.

Need for velopharyngeal surgery after primary palatoplasty in cleft patients. A retrospective cohort study and review of literature

BACKGROUND

Enabling intelligible speech plays an important role in achieving social inclusion and a good quality of life of cleft patients. A crude measure of primary palatal repair quality is the incidence of operations to correct velopharyngeal insufficiency (VPI) after speech-language therapy has proven inadequate. This study assessed the necessity for surgery to correct velopharyngeal insufficiency following our standardized two-staged protocol, compared the results with the literature, and identified factors that may influence velopharyngeal competence.

METHODS

A review of the literature was performed. The outcome measure in our series was the necessity for a secondary procedure to correct velopharyngeal insufficiency. The results of literature review were compared with the results of our case series, which we treated using a standardized protocol.

RESULTS

In our retrospective study, 5 patients (2.5%) required secondary pharyngoplasty. In literature, the frequency of surgery to correct velopharyngeal insufficiency after one- and two-stage protocols were 13.6% and 24.5%, respectively. No statistical difference was found between bilateral and unilateral clefts. The frequencies of velopharyngeal surgery were 7.2% after Furlow palatoplasty, 17.5% after a 2-flap palatoplasty, 18.6% after a Wardill-Killner palatoplasty, and 35.6% after a Von Langenbeck palatoplasty.

CONCLUSION

The literature reported that one-stage palatoplasty is correlated with a lower incidence of secondary pharyngeal surgery. Our standardized two-stage protocol proved successful in avoiding secondary velopharyngeal surgery but due to the reduced number of patients included in our study, more research is needed.

Effect of Nonradical Intravelar Veloplasty in Patients With Unilateral Cleft Lip and Palate: A Comparative Study and Systematic Review

BACKGROUND

The purpose of this study was to compare 2 techniques used for primary muscular repair and perform a systematic review of the literature to evaluate the effects of radical intravelar veloplasty (IVV) on nonsyndromic unilateral cleft lip and palate.

METHODS

This is an ambispective study between 2 groups of patients with unilateral cleft lip and palate who were operated using a radical and conservative form of IVV in Lima Peru. Data collection was accomplished by evaluation of speech development and middle ear function of the patients. A systematic review of the literature for studies published until June 2020 to evaluate the effect using the radical IVV in patients with cleft lip and palate.

RESULTS

Our comparative study did not find statistically significant differences in speech development between the studied techniques for unilateral cleft palate repair. Increased number of ear tube placements have been observed in the group treated with radical form of IVV. After systematic literature searching, 10 identified studies were qualified for the final analysis, which included 1367 patients. The overall study quality according to Oxford CEBM and GRADE scale was low.

CONCLUSIONS

The results arising from this study provides statistical evidence that one technique let us obtain better speech outcomes. A technique with conservative IVV has statistical significant fewer rate of middle ear disorders after primary cleft palate repair. Based on available scientific evidence, definitive conclusions about the effectiveness of radical IVV on velopharyngeal and middle ear function cannot be drawn.

Furlow Palatoplasty for Velopharyngeal Dysfunction Management: Auditing and Predicting Outcomes

OBJECTIVE

The Furlow palatoplasty is a proven procedure in the management of secondary velopharyngeal dysfunction in patients with cleft palate. But the selection of cases, the degree of clinical success, and the preoperative predictors of the same are less established. This study is an effort to retrospectively look at outcomes, in a large series of velopharyngeal dysfunction cases treated with the Furlow palatoplasty alone.

DESIGN

Retrospective analysis of preoperative and postoperative speech and videofluoroscopic data.

SETTING

Tertiary care center.

PATIENTS/PARTICIPANTS

Ninety-two patients who were diagnosed with velopharyngeal dysfunction post primary cleft palate repair.

INTERVENTIONS

Furlow palatoplasty for velopharyngeal dysfunction post primary cleft palate repair.

MAIN OUTCOME MEASURES

Variables analyzed were perceptual speech parameters and, closure ratios obtained from lateral video-fluoroscopic images.

RESULTS

Overall, 81.5% had postoperative improvements in their lateral video-fluoroscopic parameters, 63% improved their nasality scores, and 65.2% had improved speech intelligibility. A simple linear regression was done to predict the postoperative closure ratio. Preoperative closure ratio, hypernasality (moderate and severe), and audible nasal air emission are predictors for postoperative closure ratio.

CONCLUSIONS

The Furlow palatoplasty alone led to complete resolution, or significant improvement of velopharyngeal dysfunction in a majority of patients, despite the cohort having a wide range of severity in terms of degree of dysfunction. The predictive formula will be validated in a further study.

Predictive Factors for Velopharyngeal Insufficiency Following Primary Cleft Palate Repair

OBJECTIVE

Velopharyngeal insufficiency (VPI) remains a known complication of primary palatoplasty. We sought to identify factors associated with the incidence of VPI and create a predictive model for VPI development in our population.

DESIGN

A single-institution, retrospective review.

SETTING

Multidisciplinary clinic in a tertiary academic institution.

PATIENTS

A total of 453 consecutive patients undergoing primary palatoplasty from 1999 to 2016 were reviewed. Inclusion required follow-up past age 5. Patients who were non-verbal, and thus unable to undergo speech evaluation, were excluded.

MAIN OUTCOME MEASURES

Primary outcome was VPI, defined as revision palatoplasty or recommendation by speech-language pathology.

RESULTS

Of 318 patients included, 179 (56%) were male. Median age at primary repair was 1.0 years (0.9-1.1) with a median age of 8.8 years at last follow-up. One hundred nineteen (37%) patients developed VPI at a median age of 5.0 years (3.8-6.5). Higher rates were seen with posterior fistula (65% vs 14%, P <.01) and straight-line repair (41% vs 9%, P <.01), with lower rates in patients with Veau I clefts (22% vs 39%, P <.05). Patients with VPI were older at last follow-up. Following multivariate regression, factors remaining significant were posterior fistula (odds ratio [OR]: 11.3, 95% CI: 6.1-22.0), primary Furlow repair (OR: 0.18, 95% CI: 0.03-0.68), genetic diagnoses (OR: 2.92, 95% CI: 1.1-7.9), and age at last follow-up (OR: 1.11, 95% CI: 1.01-1.2).

CONCLUSIONS

Length of follow-up, posterior fistulae, and genetic diagnoses are associated with VPI formation. Furlow repair may protect against formation of VPI. Use of allograft, Veau class, birth type, birth weight, and race are not independently associated with VPI formation.

Core Outcome Set for Reporting Outcomes of Interventions for Velopharyngeal Dysfunction: Final Results of the COS-VPD Initiative

OBJECTIVE

To date, the recording of outcomes of interventions for velopharyngeal dysfunction (VPD) has not been standardized. This makes a comparison of results between studies challenging. The aim of this study was to develop a core outcome set (COS) for reporting outcomes in studies examining the management of VPD.

DESIGN

A two-round Delphi consensus process was used to develop the COS.

PATIENTS, PARTICIPANTS

The expert Delphi panel comprised patients and caregivers of patients with VPD, surgeons and speech and language therapists specializing in cleft palate, and researchers with expertise in VPD.

INTERVENTIONS

A long list of outcomes was derived from the published literature. In each round of a Delphi survey, participants were asked to score outcomes using the Grading of Recommendations, Assessment, Development, and Evaluations scale of 1 to 9, with 1 to 3 labeled "not important," 4 to 6 labeled "important but not critical," and 7 to 9 labeled "critical."

MAIN OUTCOME MEASURE

Consensus criteria were specified a priori. Outcomes with a rating of 75% or more of the panel rating 7 to 9 and 25% or fewer rating 1 to 3 were included in the COS.

RESULTS

A total of 31 core outcomes were identified from the Delphi process. This list was condensed to combine topic areas to produce a final COS of 10 outcomes, including both processes of care and patient-reported outcomes that should be considered for reporting in future studies of VPD.

CONCLUSIONS

Implementation of the COS-VPD will facilitate consistency of outcomes data collection and comparison of results across studies.

Functional outcomes in children with reduction glossectomy for vascular malformations - "less is more!"

OBJECTIVES

Vascular malformation (VM) of the tongue can cause true macroglossia in children. Reduction glossectomy provides primary relief when sclerotherapy has failed or is not possible. In this study, we evaluated the surgical role in functional outcome of reduction glossectomy performed for VM of the tongue.

PATIENTS AND METHODS

: We evaluated the functional and surgical outcomes of seven children who were treated at a tertiary care centre in Southern India between 2013 and 2018.

RESULTS

: Six children underwent median glossectomy, while one child underwent lateral glossectomy. Functional assessment was performed at least 2 years after the date of surgery. At the time of assessment, speech was comprehensible for three children and was occasionally unintelligible in four children. Taste and swallowing were normal in all seven children. Six children exhibited a minimal residual lesion after surgery, of which only one was symptomatic. Residual lesions were managed with sclerotherapy (n=3), observation (n=2), or repeat surgery (n=1).

CONCLUSION

Reduction glossectomy in children with macroglossia secondary to VMs has acceptable outcomes in terms of cosmesis and speech, with no gastronomic restriction.

Primary Palatal Surgery in Nonsyndromic Cleft Palate Children and Velopharyngeal Insufficiency Correction Outcomes

ABSTRACT

Speech has a very significant impact on the life quality of people with cleft and lip palate. Restore tissue anatomy and functionality is the main aim of primary palatal surgery. Multiple factors are associated with successful handling, including the need for a velopharyngeal insufficiency (VPI) secondary surgery. The study's aim is to determine speech and velopharyngeal function outcomes in children with cleft palate operated in our institution and to determine VPI secondary surgery outcomes, if appropriate. Clinical records of nonsyndromic patients with cleft palate born between January 2009 and December 2012, who performed their multidisciplinary care on our institution, were analyzed retrospectively. One hundred forty-two patients received primary palatal surgery. Eighty (56%) were male and 62 (44%) female. Twenty-two had soft cleft palate, 9 hard and soft cleft palate, 84 unilateral, and 27 bilateral cleft lip and palate. Twelve percent of patients presented palatal fistula, with a significantly higher presentation in Soft Cleft Palate and Hard and Soft Cleft Palate. Twenty-seven patients (19%) had surgical indication for VPI correction, and 20 of them received VPI surgery, before school age. Cleft type and gender were significantly associated with VPI surgery indication rate. Postsurgery, 80% presented normal resonance. Nasal emission improved in 85% of patients. Nasometry decreased from 45% to 31%. Hyponasality increased by 10%. One case presented total flap dehiscence. Preoperative planning must be done carefully and individualized to succeed. Future prospective research that considers all the variables for a correct analysis is advisable, to improve our results.

Assessment of Intelligibility in Children with Velopharyngeal Insufficiency: The Relationship between Intelligibility in Context Scale and Experimental Measures

PURPOSE

The purpose of this study was to investigate the clinical application of the Intelligibility in Context Scale (ICS) instrument in children with velopharyngeal insufficiency (VPI). This study investigated the relationship between clinical speech outcomes and parental reports of speech intelligibility across various communicative partners.

METHODS

The ICS was completed by the parents of 20 English-speaking children aged 4-12 years diagnosed with VPI. The parents were asked to rate their children's speech intelligibility across communication partners using a 5-point scale. Clinical metrics obtained using standard clinical transcription on the Picture-Cued SNAP-R Test were: (1) percentage of consonants correct (PCC), (2) percentage of vowels correct (PVC), and (3) percentage of phonemes correct (PPC). Nasalance from nasometer data was included as an indirect measure of nasality. Intelligibility scores obtained from naive listener's transcriptions and speech-language pathologists' (SLP) ratings were compared with the ICS results.

RESULT

Greater PCC, PPC, PVC, and transcription-based intelligibility values were significantly associated with higher ICS values, respectively (r[20] = 0.84, 0.82, 0.51, and 0.70, respectively; p < 0.05 in all cases). There was a negative and significant correlation between ICS mean scores and SLP ratings of intelligibility (r = -0.74; p < 0.001). There was no significant correlation between ICS values and nasalance scores (r[20] = -0.28; p = 0.22).

CONCLUSION

The high correlations obtained between the ICS with PCC and PPC measures indicate that articulation accuracy has had a great impact on parents' decision-making regarding intelligibility in this population. Significant agreement among ICS scores with naive listener transcriptions and clinical ratings supports use of the ICS in practice.

Speech Outcomes Following Orticochea Pharyngoplasty in Patients With History of Cleft Palate and Noncleft Velopharyngeal Dysfunction

OBJECTIVE

To report speech outcomes following Orticochea pharyngoplasty in 43 patients with cleft palate and noncleft velopharyngeal dysfunction.

DESIGN

A retrospective surgical audit of patients undergoing Orticochea pharyngoplasty between 2004 and 2012, with speech as a primary outcome measure.

SETTING

Patients known to a regional UK cleft center.

METHODS

Forty-three patients underwent Orticochea pharyngoplasty by a single surgeon in a UK regional cleft center. Twenty-one patients had undergone a prior procedure for velopharyngeal dysfunction. Pre- and postoperative speech samples were assessed blindly using the Cleft Audit Protocol for Speech-Augmented by a specialist cleft speech and language therapist, external to the team. Speech samples were rated on the following parameters: hypernasality, hyponasality, audible nasal emission, nasal, turbulence, and passive cleft speech characteristics. Statistical differences in pre- and postoperative speech scores were tested using the Wilcoxon matched-pairs signed-ranks test. Inter- and intrareliability scores were calculated using weighted Cohen κ.

RESULTS

Whole group: A statistically significant difference in pre- and postoperative scores for hypernasality (P < .001), hyponasality (P < .05), nasal emission (P < .01), and passive cleft speech characteristics (P < .01) were reported. Patients with cleft diagnoses: A statistically significant difference in scores for hypernasality (P < .001), nasal emission (P < .01), and passive cleft speech characteristics (P < .01) were reported for this group of patients. Patients with noncleft diagnoses: The only parameter to demonstrate a statistically significant difference was hypernasality (P < .01) in this group.

CONCLUSIONS

Orticochea pharyngoplasty is a successful surgical procedure in treating velopharyngeal dysfunction in both the cleft and noncleft populations.

Reliability of Outcome Measures to Assess Consonant Proficiency Following Cleft Palate Speech Intervention: The Percentage of Consonants Correct Metric and the Probe Scoring System

Purpose This study compared the inter- and intrarater reliability of the percentage of consonants correct (PCC) metrics and the probe scoring system between an experienced and a less experienced rater and between two experienced raters. In addition, these outcome measures' ability to reflect changes following speech intervention was measured. Method During Phase 1, two raters (Rater 1 with 5 years of experience in cleft-related speech disorders and Rater 2 with limited experience in cleft-related speech disorders) independently assessed 134 speech samples at the word and sentence levels, which were collected on different data points before, during, and following a cleft palate speech intervention. During Phase 2, a third rater (with 8 years of experience) analyzed 34 speech samples. The percentage of consonants correct-revised, the percentage of correct places and manners, and probe scores at the word and sentence levels were measured. Results Poor-to-moderate interreliability between Raters 1 and 2 was found due to differences in error classification. Interrater reliability between Raters 1 and 3 was very good for both the PCC metrics and the probe scores. The interrater reliability for the amount of targets elicited was lower compared to the interrater reliability for the amount of targets correct. The probe scoring system demonstrated a greater ability to detect changes toward the correct production of the target consonant compared to the PCC metrics. Conclusions Having an experience with the assessment of cleft-related speech disorders is a crucial factor to gain reliable results. The interrater reliability for the PCC metrics and the probe scoring system between two experienced raters did not differ, suggesting that both outcome measures can be used in cleft palate speech intervention studies. Despite the ability of the probe scoring system to detect changes, further research should provide insight in the benefits of this system both for research and clinical purposes.

English-Only Treatment of Compensatory Speech Errors in a Bilingual Adoptee With Repaired Cleft Palate: A Descriptive Case Study

Purpose The purpose of this clinical focus article is to provide a descriptive case study of a late-adopted, bilingual adolescent with cleft palate speech errors. Specifically, we examined the cross-linguistic generalization of remediated compensatory cleft errors, following treatment in English (second language) only. The overarching goal of this study is to gain insights into the complexity of speech intervention for the adopted population with delayed cleft palate repair. Method A 14-year-old female adopted from China with a repaired unilateral cleft lip and palate and maladaptive articulation errors underwent 55 one-hour sessions of a motor-based, speech therapy approach over a 15-month span, targeting English phonemes only. Pre-, mid-, and posttreatment evaluation included perceptual and instrumental assessment of speech and resonance. Outcome measures at each time point included perceptual speech and resonance ratings, nasometry scores, and percent consonants correct (PCC) in both English and Mandarin. Results PCC in English improved from 60% in single words and 35% in sentences pretreatment to 100% in single words and sentences during posttreatment assessment. Without direct treatment in Mandarin, PCC in Mandarin improved from 56% in single words and 50% in sentences pretreatment to 100% in single words and 99% in sentences during posttreatment assessment. Posttreatment nasometry scores decreased by 20% for the nasal sample and 17% for the oral sample compared to pretreatment. Conclusions This descriptive case study demonstrated successful remediation of cleft palate speech errors, following 15 months of treatment in a late-adopted bilingual adolescent using a motor-based therapy approach. Treatment of errors in English (second language) led to generalization of correct productions in Mandarin (first language). This study presents the potential for bilingual late adoptees to achieve intelligible speech in both languages when motor-based therapy principles are applied to intervention.

The effect of velopharyngeal insufficiency on voice quality in Estonian Children with Cleft Palate

Most children born with cleft palate (CP) or cleft lip and palate (CL/P) have velopharyngeal insufficiency (VPI), some degree of hypernasal resonance, articulation disorders and laryngeal dysphonia. Combination of different CL/P specific problems may mask laryngeal dysphonia and therefore, it may remain undiagnosed and untreated by clinicians. The research aimed to study the effect of VPI on voice quality in Estonian CL/P children. We included 18 CL/P and 79 healthy children. Combination of objective (Multi-Dimensional Voice Program (MDVP)) and subjective (Pediatric Voice Handicap Index (pVHI), GRBAS scale, video-nasoendoscopy (VNE), video-laryngostroboscopy (VLS)) assessment methods were assisted and performed by our multidisciplinary cleft teams. We found that (1) overall quality of life is greatly affected by voice, resonance and articulation disorders in CL/P group, (2) more than half of the CL/P children had morphological changes of the vocal folds, (3) the severity of VPI did not result in worse outcomes of acoustic parameters of voice.

Speech pathology telepractice intervention during the COVID-19 pandemic for Spanish-speaking children with cleft palate: A systematic review

BACKGROUND

Due to the lockdown and quarantines caused by the COVID-19 pandemic, the need to study and use telepractice for providing speech pathology interventions for children with cleft palate has arisen.

OBJECTIVE

To carry out a systematic review of the use of telepractice during the COVID-19 pandemic for providing speech pathology interventions for Spanish-speaking children with cleft palate.

METHODS

In July and August 2020, the authors searched the electronic databases Medline, LILACS, SciELO, and the Cochrane Library using the following keywords in English (MeSH): Cleft palate combined with Early intervention, Speech therapy, Rehabilitation of speech and language disorders, Speech production measurement, Speech articulation tests and Telemedicine. Original articles were selected and analyzed, complemented by an analysis of flowcharts and recommendations by the GES Clinical Guide of Cleft Lip and Palate of Chile's Government and the authors' expert opinions.

RESULTS

A total of 2680 articles were retrieved, of which 23 were critically analyzed and used to adapt the early stimulation, evaluation, and treatment of children with CP to speech therapy telepractice at the Gantz Foundation, a Hospital in Santiago de Chile.

LIMITATIONS

Only three researchers carried out a quick review, which limited the depth of individual analysis of the studies included. Also, the suggestions and material presented should be evaluated in future investigations.

CONCLUSION

This systematic review provides useful guidelines for providing speech pathology interventions through telepractice for children with cleft palate. Audiovisual materials seem to be extremely useful for families receiving the interventions. The use of interactive videos for Spanish-speaking children and educational videos for parents is manifest.

Outcomes of Furlow Double-Opposing Z-Plasty Palatoplasty for the Treatment of Symptomatic Overt and Occult Submucous Cleft Palate: A Comparison Study

BACKGROUND

The submucous cleft palate can be overt or occult and may require surgical repair. The double-opposing Z-plasty (Furlow repair) is the authors' center's preferred approach. This study evaluated complication rates, differences in outcome between overt and occult types, and patient factors associated with surgical failure.

METHODS

This retrospective study reviewed documentation on all patients who underwent Furlow Z-plasty for submucous cleft palate at a single center between 2004 and 2018. Speech pathology was quantified using the Pittsburgh Weighted Speech Score.

RESULTS

A total of 351 patients were included (125 overt and 226 occult cases). Furlow Z-plasty was successful (postoperative Pittsburgh Weighted Speech Score <7 without recommendation for secondary speech surgery) in 291 patients (82.1 percent). Apart from those requiring secondary surgery, there were no documented complications. Occult-type patients were 7.5 years old at palatoplasty with a speech score of 14.1; overt-type patients were 6.5 years old with a score of 15.7. Postoperative speech scores were similar for both groups. Secondary speech surgery patients had a higher preoperative score (16.9 versus 14.2). Age at time of palatoplasty and submucous cleft palate type were not predictive of the need for secondary surgery. Syndromic patients had higher preoperative and postoperative speech scores (15.6 and 7.5, respectively) than nonsyndromic patients (14.3 and 4.3) and needed secondary surgery more often (24.4 percent versus 9.2 percent). V-shaped velar vaulting on preoperative assessment was present in 92 percent of occult-type patients.

CONCLUSIONS

Furlow palatoplasty is a safe and effective means of repairing submucous cleft palate. Patients with the occult type presented later with a lower Pittsburgh Weighted Speech Score. High preoperative speech score and syndromic status were associated with the need for secondary speech surgery. V-shaped velar vaulting is a reliable sign of occult submucous cleft palate.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Risk, II.

The Relationship Between Maxillary Growth and Speech in Children With a Unilateral Cleft Lip and Palate at 5 Years of Age

OBJECTIVE

This study sought to investigate the association between maxillary growth and speech outcomes for children with a repaired unilateral cleft lip and palate (UCLP) at 5 years of age.

PARTICIPANTS

In all, 521 children (180 females and 341 males) with a nonsyndromic complete UCLP, born between 2007 and 2012 in England, Wales, and Northern Ireland were included in this study.

OUTCOME MEASURES

Maxillary growth was analyzed using dental models scored by the 5-Year-Olds' index, and perceptual speech analyses were scored by the Cleft Audit Protocol for Speech - Augmented rating.

RESULTS

Forty-one percent of the children achieved good maxillary growth (scores 1 and 2 on 5-Year-Old' index). Fifty percent of the children achieved normal speech (achieving UK speech standard 1). Maxillary growth was not found to have an impact on speech outcome when described by the 3 UK National Cleft Lip and Palate Speech Audit Outcome Standards. Analysis according to individual speech parameters showed dentalizations to be less prevalent in children with good maxillary growth compared to fair and poor growth (P = .001). The remaining speech parameters within resonance, nasal airflow, and articulation categories were not significantly associated with maxillary growth.

CONCLUSION

The findings from this study suggest that children with a history of complete UCLP, who have poor maxillary growth, are not at a higher risk of having major speech errors compared to children with good or fair maxillary growth at 5 years of age.

A Comparison of Outcomes After Palatoplasty in Patients With Non-Syndromic Pierre Robin Sequence Versus Patients With Non-Syndromic Isolated Cleft Palate

The purpose of this retrospective study was to compare outcomes of cleft palate repair in patients with non-syndromic Pierre Robin sequence (NS-PRS) versus those with non-syndromic isolated cleft palate (NS-ICP). Pierre Robin sequence (PRS) was defined as a diagnosis of the triad of microretrognathia, glossoptosis, and cleft palate, and the severity of PRS was assessed based on the presence of respiratory and feeding problems. All patients underwent palatoplasty between January 2000 and December 2011. The authors examined age at palatoplasty, type of cleft palate, fistula rate, velopharyngeal (VP) function, nasal emission, hypernasality, and need for secondary speech surgery, in addition to PRS severity in the NS-PRS patients. A total of 15 NS-PRS patients and 40 NS-ICP patients were reviewed. The incidence of VP dysfunction, nasal emission, hypernasality, and secondary speech surgery was not significantly different between the NS-PRS patients and NS-ICP patients. Age at palatoplasty was significantly different between the 2 groups (P = 0.012) but type of CP was not (P = 1.00). Only 2 NS-PRS patients were classified as category III (severe), and all of the NS-PRS patients who had VP insufficiency were classified as PRS severity category I (not severe). The findings of this study indicate that NS-PRS patients may not have worse outcomes than NS-ICP patients.

Furlow Palatoplasty: Should We Also Focus on the Size of the Nasopharynx?

OBJECTIVES

(1) To determine the incidence rate of velopharyngeal dysfunction (VPD) according to 7 speech criteria post-Furlow palatoplasty. (2) To find an anatomical measurement of the cleft palate (or combination of measurements) associated with the occurrence of VPD.

STUDY DESIGN

Retrospective cohort study.

PARTICIPANTS AND METHODS

Fifty-six patients with cleft palate ± cleft lip underwent palatoplasty with the Furlow technique at the age of 10 months. Pre-and post-palatoplasty cleft palate measurements were collected during the procedure. Three blinded speech-language pathologists (SLPs) retrospectively scored the patients from the chart data at age 4. Student t test and receiver operating characteristic curve analysis were used to evaluate the association and predictive capacity between cleft measurements and parameters (M&P) with all VPD criteria.

RESULTS

The SLPs found an incidence of VPD according to 7 criteria: hypernasality (11%), audible nasal emission (4%), nasal rustle (14%), compensatory errors (4%), impairment of speech understandability (7%), and impairment of speech acceptability (16%). The SLPs recommended a secondary surgical procedure in 5 patients (9%). A statistically significant association was found between, respectively, 17 and 5 M&P and the occurrence of compensatory errors and audible nasal emission. Our data suggest that the length of the cleft, the cleft area, and the postoperative transversal size of the nasopharynx are the best indicators of the future positivity of VPD criteria.

CONCLUSION

The size of the postoperative transverse nasopharyngeal area during the primary cleft palate procedure may become the focus of the next generation of cleft surgeons to reduce the incidence of VPD.

Long-term Speech Outcomes of Cleft Palate Repair in Robin Sequence versus Isolated Cleft Palate

Supplemental Digital Content is available in the text.

Whether treatment of cleft palate (CP) associated with Robin sequence (RS) should attain outcomes similar to those of isolated cleft palate (ICP) remains unknown. This study compares treatment and outcomes in both conditions and delineates predictors of long-term outcome.

Late Primary Palatoplasty in Skeletally Mature Patients: Obstacles and Outcomes

BACKGROUND

As the performance of late primary palatoplasty for skeletally mature patients remains controversial, there is little data available regarding speech outcomes for this patient population. The purpose of this study therefore is to identify and evaluate the impact of speech outcomes following late palate repair on skeletally mature patients.

METHODS

A retrospective study was performed on 19 consecutive skeletally mature patients who underwent late primary palate repair between 2010 and 2018. Speech assessment was performed preoperatively, between 3 and 6 months postoperatively, and then after 6 months postoperatively. Levels for hypernasality, oral pressure, and audible nasal air emission were scored and recorded.Patients were stratified by age, gender, presence of postoperative fistula, and Veau cleft type, in order to determine the impact of each variable on final speech outcomes. The Kruskal-Wallis test was used to compare the preoperative speech assessment with the postoperative speech outcomes, and the Mann-Whitney test was used to analyze the impact of the above variables on final speech outcomes.

RESULTS

Our data showed overall postoperative speech improvement for all tested variables. Patients without postoperative fistula presented better results in oral pressure than those patients with postoperative fistula (P < 0.05). None of the other tested variables presented a significant negative impact on speech outcomes.

CONCLUSION

Late primary palatoplasty significantly improves speech outcomes for skeletally mature patients. Fistula has a negative impact on oral pressure.

The Lima Surgical Protocol for Cleft Palate Repair

BACKGROUND

A cleft team experience addressing non-syndromic cleft palate and cleft lip and palate is presented. The purpose of the present study is to compare surgical outcomes using 2 different protocols for cleft palate repair provided by a cleft team in Lima, Perú.

METHODS

This is a comparative study between 2 groups of patients with non-syndromic cleft palate who were operated using different surgical protocols from 1999 to 2014. One hundred twenty-four children with non-syndromic isolated cleft palate and cleft lip and palate treated from 2007 to 2014 using a surgical protocol developed by our cleft team in Lima, Perú were compared with 145 children with cleft palate and cleft lip and palate treated by the same team using different protocol from 1999 to 2007. Data collection was accomplished by evaluation of symptomatic oronasal fistulas, presence of velopharyngeal insufficiency (VPI) and postoperative complications.

RESULTS

Statistical significant differences were observed between the 2 groups regarding the development of flap necrosis in favor of the Lima protocol. No significant difference in palatal fistula and VPI rate between the 2 protocols was found.

CONCLUSIONS

The Lima Surgical Protocol for cleft palate repair is an alternative strategy which uses the strengths of different surgical techniques based on the severity of the cleft. We observed better surgical outcomes using the Lima protocol with regards to postoperative complications in patients with non-syndromic cleft palate.

Perceptual Speech Outcomes After Early Primary Palatal Repair in Ugandan Patients With Cleft Palate

OBJECTIVE

To provide speech outcomes of English-speaking Ugandan patients with a cleft palate with or without cleft lip (CP±L).

DESIGN

Prospective case-control study.

SETTING

Referral hospital for patients with cleft lip and palate in Uganda.

PARTICIPANTS

Twenty-four English-speaking Ugandan children with a CP±L (15 boys, 9 girls, mean 8.4 years) who received palatal closure prior to 6 months of age and an age- and gender-matched control group of Ugandan children without cleft palate.

INTERVENTIONS

Comparison of speech outcomes of the patient and control group.

MAIN OUTCOME MEASURES

Perceptual speech outcomes including articulation, resonance, speech understandability and acceptability, and velopharyngeal composite score (VPC-sum). Information regarding speech therapy, fistula rate, and secondary surgery.

RESULTS

Normal speech understandability was observed in 42% of the patients, and 38% were judged with normal speech acceptability. Only 16% showed compensatory articulation. Acceptable resonance was found in 71%, and 75% of the patients were judged perceptually to present with competent velopharyngeal function based on the VPC-sum. Additional speech intervention was recommended in 25% of the patients. Statistically significant differences for all these variables were still observed with the control children (P < .05).

CONCLUSIONS

Overall, acceptable speech outcomes were found after early primary palatal closure. Comparable or even better results were found in comparison with international benchmarks, especially regarding the presence of compensatory articulation. Whether this approach is transferable to Western countries is the subject for further research.

Influence of speech stimuli in the auditory perceptual identification of hypernasality in individuals with cleft lip and palate

PURPOSE

To investigate the influence of speech stimuli in the auditory perceptual identification of hypernasality in individuals with Cleft Lip and Palate (CLP).

METHODS

Speech samples from 80 individuals with operated unilateral CLP, ages ranged from nine to 17 years (the mean age of: 12y7m), both genders, were edited for this study. Samples were recorded over the production of nine different speech stimuli, including counting and short sentences characterized by oral sounds, one loaded with low pressure consonants and seven loaded with high pressure consonants. Three speech-language pathologists rated the presence or absence of hypernasality while analyzing 864 recordings (80 individuals X 9 stimuli + 144 repeated recordings, for measuring the intra-rater agreement). Intra-rater and inter-rater indexes of agreement were established for all nine stimulus conditions. The indexes of inter-rater agreement were compared using the Z test (p<0.005), with samples comprising significant indexes of agreement interpreted as better stimuli for identifying the hypernasality in these individuals.

RESULTS

Intra-rater agreement for high pressure stimuli with voiced consonants were significantly lower than indexes for other stimuli. Inter-rater agreement between each pair of SLPs ranged from 0.11 (plosive voicing stimuli) to 0.57 (12 short sentences, one of each high pressure consonant). The values of mean inter-rater agreement between all SLPs was 0.47 indicating moderate agreement for identifying hypernasal speech.

CONCLUSION

Speech recordings obtained over the production of longer speech samples including 12 short sentences, for instance one for each high pressure consonant, may favor inter-rater agreement for identifying hypernasality.