The Cleft Audit Protocol for Speech—Augmented: A Validated and Reliable Measure for Auditing Cleft Speech

Speech and hearing in adults with 22q11.2 deletion syndrome

The purpose of the study was to investigate the prevalence of velopharyngeal impairment, compensatory articulation, reduced intelligibility, and to rate the general impression of speech in adults with 22q11.2 deletion syndrome. The second purpose was to study the prevalence and type of hearing impairment in these adults. A referred, consecutive series of 24 adults with confirmed 22q11.2 deletion, 16 female and 8 males, with a mean age of 25 years (19-38 years) was included in the study. A blind assessment of speech by three experienced speech-language pathologists was performed. Sixteen (66%) patients had a mild to severe velopharyngeal impairment. The most prevalent symptoms of velopharygeal impairment were hypernasality and audible nasal airflow. The mean nasalance score was 33% (6-66%). Only two patients had disordered articulation; one of these had glottal articulation. A mean of 96% (88-100%) of single words were rated to be intelligible. To achieve these results half of the patients previously had velopharyngeal flap surgery. Forty-one percent (9/22) had mild-moderate hearing impairment; three had sensorineural type, four conductive and two had a mixed type. In conclusion the majority of the patients had no articulation errors and good intelligibility; while one-third still had moderate to severe problems with velopharyngeal impairment. Around 40% still had some hearing impairment, in most cases with a mild to moderate conductive component. Thus, a high prevalence of speech and hearing problems seems to be a part of the phenotype in adults with 22q11.2DS.

Long-Term, Longitudinal Follow-Up of Individuals with Unilateral Cleft Lip and Palate after the Gothenburg Primary Early Veloplasty and Delayed Hard Palate Closure Protocol: Speech Outcome

Objective

To investigate long-term, longitudinal speech outcome in patients born with unilateral cleft lip and palate treated according to a two-stage primary palatal protocol with early veloplasty and delayed hard palate closure.

Design

Retrospective, longitudinal cohort study.

Setting

A university hospital in western Sweden.

Subjects

A consecutive series of 55 patients from the total cohort of 65 were included. All patients had surgical procedures at Sahlgrenska University Hospital, Gothenburg, Sweden.

Methods

Standardized audio recordings were blindly analyzed at 5, 7, 16, and 19 years of age and after at a clinical visit at 10 years of age. Typical cleft speech variables were rated independently on ordinal scales. Intelligibility and perceived velopharyngeal function were assessed also. Prevalences of speech characteristics were determined, and interrater and intrarater agreement were calculated.

Results

Prominent hypernasality, nasal air leakage, and retracted oral articulation at 5 years were markedly reduced throughout the years with low prevalences at ages 16 and 19 years. Perceived velopharyngeal competence was noted in 82% at age 16 and 87% at age 19 years along with normal intelligibility. Pharyngeal flap surgery was performed in 6 of the 55 patients (11%).

Conclusions

Long-term speech outcome in patients with two-stage palatoplasty with early soft palate repair was considered good and improved even before hard palate repair. The typical retracted oral articulation was quite frequent during the early ages; whereas, nonoral misarticulations were almost nonexistent, implying good velopharyngeal competence.

Características acústicas da oclusiva glotal associada à sequência de Pierre Robin: estudo de caso

A fissura de palato, em associação à Sequência de Pierre Robin, pode favorecer o desenvolvimento de produções atípicas (compensatórias), na fala da criança, como é o caso da oclusiva glotal (golpe de glote) comumente observada em substituição aos sons oclusivos (vozeados ou não). No presente estudo, foi realizada a análise dos parâmetros fonético-acústicos da oclusiva glotal produzidas em /k/ e /g/ por uma criança do gênero feminino, com 5 anos, que apresentava fissura de palato reparada, associada à Sequência de Pierre Robin. Para isso, foram selecionadas seis palavras em que a oclusiva velar encontrava-se na posição inicial da palavra e combinada com as vogais /a/, /i/ e /u/ na posição acentuada. Foi ainda realizado julgamento perceptivo-auditivo por três fonoaudiólogos, que apresentou concordância quanto à presença da oclusiva glotal de 100% para ambas as relações (intra e inter-juízes). Na inspeção dos dados via espectrograma foi observada variabilidade dos parâmetros espectrais (burst e transição formântica) e essas variações também puderam ser computadas considerando as vogais separadamente. A análise estatística revelou diferença estatisticamente significante entre as duas consoantes velares (/k/ e /g/) nos parâmetros espectral (burst), temporal (VOT e duração relativa da oclusiva na palavra) e os relativos às características acústicas das vogais adjacentes às oclusivas (período estacionário de F3). Por fim, as características acústicas da oclusiva glotal sugeriram que a criança pode ter utilizado de estratégias para marcar contrastes fônicos na língua, ainda que os mesmos não tenham magnitude suficiente para serem resgatados auditivamente pelo ouvinte.

Perceptions of Audible Nasal Emission in Speakers with Cleft Palate: A Comparative Study of Listener Judgments

Objective

Audible nasal emission is a common speech distortion observed in persons with cleft palate. This study examined the validity and reliability of perceptual judgments of audible nasal emission using interval scaling and magnitude estimation techniques.

Participants

Speech samples were collected from six adolescents with repaired cleft palate, all of whom demonstrated audible nasal emission. A total of 31 adults performed rating tasks in which they judged the severity of audible nasal emission in speech samples.

Measures

Occurrences of audible nasal emission in speech samples were identified using visual and auditory inspection. Using an acoustic modification technique, samples were digitally modified to amplify perceived occurrences of audible nasal emission to create three stimulus conditions. The original recording of the speech samples served as a control condition. The severity of audible nasal emission in the samples was judged by multiple listeners using interval scaling and magnitude estimation without a modulus. Statistical analysis included analysis of variance, regression, and curve-fitting methods.

Results

Magnitude-estimation ratings demonstrated stronger evidence of validity and reliability than interval scaling. A curvilinear relationship was found between the sets of ratings.

Conclusions

The results of this study suggest that audible nasal emission may be a prothetic or ratio-level perceptual continua. Listeners should consider using magnitude estimation or other ratio-based methods for perceptual judgments of audible nasal emission.

Communication and cognition profiles in parents of children with nonsyndromic cleft lip and/or palate

The main aim of the study was to ascertain whether parents of children with nonsyndromic cleft lip and/or palate (P-CLP) perform differently than parents of children without CLP (P-control) on a nonword repetition (NWR) test. Given that children with CLP frequently demonstrate communication and cognitive difficulties, a link between NWR performance and group would lend support to a familial risk factor in nonsyndromic CLP. The NWR test, a well-documented assessment to identify language and cognitive impairment, was used, together with a parent questionnaire to gather demographic data and family history information on medical, communication, and/or cognitive difficulties for 260 parents. Group differences on NWR performance and family history of communication and cognition difficulties were not demonstrated. Also, no significant difference on NWR score was seen in the P-CLP group based on child's CLP type. Correlation analysis showed that having more years of schooling, English as the dominant language, living in private housing, and being in skilled occupations were positively correlated to NWR score. Controlling for these known background variables did not alter NWR performance between P-CLP and P-control, however, only years of schooling significantly and consistently predicted NWR performance. Having significantly fewer years of schooling in the P-CLP group could be suggestive of an increased risk of communication and cognitive difficulties these parents face, and the potential difficulties their children with CLP may encounter. These results may inform early and rigorous intervention strategies for children with CLP.

Expressive language skills in Chinese Singaporean preschoolers with nonsyndromic cleft lip and/or palate

OBJECTIVE

The main objective of the present study was to examine THE EXPRESSIVE LANGUAGE SKILLS and obtain a prevalence estimate of expressive language IMPAIRMENT (not skills) in Chinese Singaporean preschoolers with nonsyndromic cleft lip and/or palate (CLP).

METHODS

A group of 43 Chinese Singaporean preschoolers aged 3 to 6 years with a diagnosis of nonsyndromic CLP was assessed using the Singapore English Action Picture Test (SEAPT). The SEAPT is an English Language screening tool standardised on typically developing English-Mandarin Chinese Singaporean preschoolers that assesses expressive vocabulary and grammatical usage. A grammar and/or information score below the 20(th) percentile on the SEAPT is indicative of an expressive language impairment. In addition, the medical records of this cohort were examined retrospectively for documentation of surgical timings, audiological history, articulation and resonance.

RESULTS

Based on the results of the SEAPT, 33% of the preschoolers with CLP were identified as having a-possible expressive language impairment. Hence, the likelihood that a child with CLP with normal cognitive functioning will have an expressive language impairment is between 3.9 to 12.7 times more likely than in the general population. There was no statistical significance when comparisons were made between dominant language groups or CLP groups on SEAPT measures of information and grammar content. Significantly more males than females were identified with language difficulties, relative to the sex ratio in the sample. No significance was found for the other participant variables.

CONCLUSIONS

The findings of this study suggest that Chinese Singaporean preschoolers with CLP have more difficulty in the expressive use of grammar and vocabulary than their peers of typical development, with significantly more males affected than females. As language performance was not related to hearing, articulation or resonance; these early results suggest that a comprehensive investigation of cognition, literacy and family aggregation of communication disorders is urgently warranted to study other possible aetiologies for language impairment in children with CLP in Singapore.

A comparative study of two acoustic measures of hypernasality

PURPOSE

This study aimed to compare 2 quantitative acoustic measures of nasality in children with cleft lip and palate (CLP) and healthy controls using formalized perceptual assessment as a guide.

METHOD

Fifty participants (23 children with CLP and 27 age- and gender-matched healthy controls) aged between 4 and 12 years produced a variety of high and low vowels that allowed perceptual ratings of nasal resonance severity as well as acoustic analysis of spectral changes. Two objective measures of nasality were used: 1/3 octave spectra analysis and the voice low tone high tone ratio. Each respective technique has been evaluated in previous research, and their potential as an effective means of detecting changes in nasal resonance has been demonstrated.

RESULTS

Only 1/3 octave spectra analysis differentiated between participants with hypernasal speech and those perceived to have normal nasal resonance. Significant differences were also observed between varying levels of perceived severity on vowels within nonnasalized phonemic environments (/pIt/, /tIp/).

CONCLUSIONS

Perceptual judgment remains the primary means of evaluating levels of nasality in children with CLP. However, the development and validation of easy-to-use objective techniques remains an important goal for effective clinical and empirical practice.

Standardization of pitch-range settings in voice acoustic analysis

Voice acoustic analysis is typically a labor-intensive, time-consuming process that requires the application of idiosyncratic parameters tailored to individual aspects of the speech signal. Such processes limit the efficiency and utility of voice analysis in clinical practice as well as in applied research and development. In the present study, we analyzed 1,120 voice files, using standard techniques (case-by-case hand analysis), taking roughly 10 work weeks of personnel time to complete. The results were compared with the analytic output of several automated analysis scripts that made use of preset pitch-range parameters. After pitch windows were selected to appropriately account for sex differences, the automated analysis scripts reduced processing time of the 1,120 speech samples to less than 2.5 h and produced results comparable to those obtained with hand analysis. However, caution should be exercised when applying the suggested preset values to pathological voice populations.

Speech assessment in cleft palate patients: a descriptive study

OBJECTIVE

Speech disorders could affect the intelligibility, but also social competence and emotional development of a cleft-palate child. In this study, we proposed to examine the phono-articulatory defects of a group of surgically treated cleft palate patients, relatively to the familial social background, and children ability of self-controlling during spontaneous language.

METHODS

Sixty-eight children (22 males and 46 females) mean age 6.87 years, affected by a non-syndromic isolated cleft of the palate underwent to the same surgical protocol. Linguistic level was evaluated using the speech assessment protocol of Accordi and colleagues that focuses on intelligibility, nasality, nasal air escape, pharyngeal friction, and glottal stop. Each of these parameters is evaluated on a four-point scale, ranging from 0 to 3. Spearman rank order correlation was used to detect significant association between analyzed parameters; also the patient social background was considered for statistical analysis.

RESULTS

The 5.88% of the sample had a negative result, with a severe to moderate degree of nasality and nasal air escape, presence of pharyngeal friction and glottal stop and, obviously a systematic compromising of the intelligibility. Also grimace was evident. The 38.23% of the sample showed an acceptable phonological outline; nasality and nasal air escape were mild, and the intelligibility resulted normal. Thirty-eight children (55.88%) showed a perfectly normal speech. Statistical analysis (Spearman rank order correlation) revealed a positive correlation between the severity of nasality and nasal air escape and the patient social contest of life (p</=0.05); moreover, there was a positive correlation between nasality and nasal air escape with the final intelligibility (p<or=0.05), and between the intelligibility and the patient social contest of life.

CONCLUSION

Phonetic and phonological development in cleft child are not only due to the surgical strategies and the surgeon experience, but also influenced by the willingness to collaborate of the patient and especially of the parents, the timeliness of the logopaedic intervention, and by inborn capabilities of the child to control the emission of the air from nasal and oral cavities.

Methodology for speech assessment in the Scandcleft project--an international randomized clinical trial on palatal surgery: experiences from a pilot study

OBJECTIVE

To present the methodology for speech assessment in the Scandcleft project and discuss issues from a pilot study.

DESIGN

Description of methodology and blinded test for speech assessment. Speech samples and instructions for data collection and analysis for comparisons of speech outcomes across five included languages were developed and tested. PARTICIPANTS AND MATERIALS: Randomly selected video recordings of 10 5-year-old children from each language (n = 50) were included in the project. Speech material consisted of test consonants in single words, connected speech, and syllable chains with nasal consonants. Five experienced speech and language pathologists participated as observers.

MAIN OUTCOME MEASURES

Narrow phonetic transcription of test consonants translated into cleft speech characteristics, ordinal scale rating of resonance, and perceived velopharyngeal closure (VPC). A velopharyngeal composite score (VPC-sum) was extrapolated from raw data. Intra-agreement comparisons were performed.

RESULTS

Range for intra-agreement for consonant analysis was 53% to 89%, for hypernasality on high vowels in single words the range was 20% to 80%, and the agreement between the VPC-sum and the overall rating of VPC was 78%.

CONCLUSIONS

Pooling data of speakers of different languages in the same trial and comparing speech outcome across trials seems possible if the assessment of speech concerns consonants and is confined to speech units that are phonetically similar across languages. Agreed conventions and rules are important. A composite variable for perceptual assessment of velopharyngeal function during speech seems usable; whereas, the method for hypernasality evaluation requires further testing.

Midface osteotomy versus distraction: the effect on speech, nasality, and velopharyngeal function in craniofacial dysostosis

OBJECTIVE

To assess speech outcomes following midface advancement and to explore whether the type of advancement surgery affects speech differently in patients with craniofacial dysostosis.

DESIGN

Prospective, before-after group design.

SUBJECTS

Fifteen consecutive patients were included in the study. Eight underwent advancement by osteotomy and seven by distraction. All patients were seen preoperatively and at least once postoperatively.

MAIN OUTCOME MEASURES

Percentage of consonants correct, nature and type of articulation errors, nasalance score, severity ratings of resonance and of velopharyngeal function using nasendoscopy and lateral videofluoroscopy, and amount of forward advancement.

RESULTS

No statistically significant differences were found between groups for pre- and postoperative changes of percentage of consonants correct (p = .755, median difference 3.0, 95% confidence interval for median difference [-14.22, 20.22]) and nasalance (p = .171, median difference = -12.00, 95% confidence interval for median differences [-30.46, 6.46]). There was no statistically significant correlation between amount of forward advancement and nasalance (r = .87, p = .799) and percentage of consonants correct (r = -.550, p = .064). Findings from lateral videofluoroscopy and nasendoscopy are described. Individual changes of speech outcomes are reported.

CONCLUSIONS

In view of the small sample size, results need to be interpreted with caution. However, the study adds to current limited knowledge with this clinical group. Further research with bigger sample sizes and randomization of patients into the different surgical groups is warranted.

A study of speech, language, hearing, and dentition in children with cleft lip only

OBJECTIVE

To examine the prevalence of speech, language, hearing, and dental problems in children with an initial diagnosis of isolated cleft lip only (CL), for which evidence-based practice can be developed.

DESIGN

Retrospective chart review of 95 patients with cleft lip (age range, 2.8 to 3.7 years; mean, 3.1 years).

RESULTS

Speech and language impairment was documented in 13% and 18% of the patients, respectively. Thirty-three percent of the children presented with middle ear effusion. Thirteen percent had abnormal hearing. With one exception, the type and degree of hearing loss was a mild conductive loss most often attributed to the presence of effusion. Dental and/or occlusal anomalies were documented in 62% of the patients. A supernumerary tooth was the most frequently occurring dental anomaly and crossbite the most frequently occurring occlusal anomaly. Two children had a submucous cleft palate. Resonance was abnormal in 5% of the children.

CONCLUSION

Children with an initial diagnosis of CL need to be monitored by the interdisciplinary team for speech, language, ear disease, hearing, and dentition beginning in infancy and followed until all management needs are met.

Universal Parameters for Reporting Speech Outcomes in Individuals with Cleft Palate

Objective:

To achieve consistency and uniformity in reporting speech outcomes in individuals born with cleft palate with or without cleft lip using perceptual parameters that characterize their speech production behavior regardless of the language or languages spoken.

Design:

A working group of six individuals experienced in speech and cleft palate was formed to develop a system of universal parameters for reporting speech outcomes in individuals born with cleft palate. The system was adopted in conjunction with a workshop held in Washington, D.C., that was devoted to developing the universal system. The system, which was refined further following the workshop, involves a three-stage plan consisting of (1) evaluation, (2) mapping, and (3) reporting. The current report focuses primarily on the third stage, reporting speech outcomes.

Results:

A set of five universal speech parameters has been devised for the reporting stage. These consist of (1) hypernasality, (2) hyponasality, (3) audible nasal air emission and/or nasal turbulence, (4) consonant production errors, and (5) voice disorder. Also included are speech understandability and speech acceptability, global parameters that can be reported for any type of speech disorder. The parameters are described in detail, and guidelines for speech-sampling content and scoring procedures in relation to the parameters are presented.

Conclusion:

A plan has been developed to document speech outcomes in individuals with cleft palate, regardless of the spoken language, using a set of five universal reporting parameters and two global speech parameters.

Satisfaction with treatment outcome in bilateral cleft lip and palate patients

The aim of this case-controlled study was to assess satisfaction with facial appearance and function, and health-related quality of life (HRQL) in bilateral cleft lip and palate patients (BCLP). The study sample was composed of adult BCLP subjects and controls matched for age, gender and socioeconomic status. Outcome measures included a self-administered questionnaire evaluating satisfaction with facial appearance, function and HRQL. Bivariate statistics were computed to analyse the association between BCLP status and outcome measures. Forty-three treated adult BCLP patients (mean age 28.2 years, SD 7.8) were compared to 43 controls without clefts (mean age 28.5 years, SD 8.0). Quantitative and qualitative assessment revealed that BCLP patients were significantly less satisfied with the appearance of the upper lip, the nose and nasal breathing. Additionally, satisfaction with facial appearance correlated positively with HRQL. For speech, hearing and drinking, quantitative scores did not differ between BCLP and controls, while qualitative assessment revealed that BCLP patients had considerable problems and concerns with these functions. This study underlines the importance of qualitative assessment of patient satisfaction with treatment outcome to identify individual problems and concerns not revealed by quantitative measures alone.