Investigating the Impact of Patient-Related Factors on Speech Outcomes at 5 Years of Age in Children With a Cleft Palate

Velopharyngeal insufficiency after cleft palate repair in patients with isolated Robin sequence versus isolated cleft palate: A systematic review

BACKGROUND

Robin sequence (RS) is characterized by micrognathia, glossoptosis, and upper airway obstruction, and is often combined with a cleft palate. It is unclear whether RS negatively impacts the development of velopharyngeal incompetence (VPI) and attainable speech outcomes. This study systematically reviewed speech outcomes in patients with cleft and isolated RS (IRS) compared with only isolated cleft palate (ICP).

METHODS

A literature search following the preferred reporting items for systematic reviews and meta-analyses (PRISMA) guidelines was performed using the PubMed and EMBASE databases. Articles reporting speech outcomes following primary palatoplasty in patients with IRS only or IRS versus ICP were identified. Study characteristics and methods, primary- and VPI palatoplasty, speech measurements, and post-operative complications were collected. Primary outcomes included VPI and need for speech correcting surgery (SCS). Methodological quality was appraised using the methodological index for non-randomized studies (MINORS) criteria (range: 0-16 and 0-24).

RESULTS

Nineteen studies reported VPI event rates that varied between 14% and 88% for IRS and 0% and 62% for ICP. Five out of 8 studies (67%) comparing VPI event rates between IRS and ICP found no significant difference. SCS rates varied between 0% and 48% for IRS and 0% and 24% for ICP. Six out of 9 studies (67%) comparing SCS rates between IRS and ICP, found no significant difference. Combined VPI event rates were 36.1% for the IRS group and 26% for the ICP group, for SCS rates this was 20% for IRS and 13% for ICP.

CONCLUSION

Most articles found no significant difference between the VPI and SCS rates indicating that speech outcomes might be similar in patients with IRS and ICP. To better compare these groups a standardized international protocol is needed.

Cleft Lip Scar Appearance is Associated With Speech Outcomes After Primary Palatoplasty

OBJECTIVE

This study aims to investigate the correlation between the quality of cleft lip scar and velopharyngeal insufficiency (VPI).

METHODS

Clinical photographs from 56 patients with repaired cleft lip and palate (CLP) were collected and anonymized by cropping the image to the region of interest around the lip and nose. A survey displaying each cleft lip scar image with five associated scar quality features, including scar color, thickness, width, lip shortening, and overall appearance, was distributed. Surveys were distributed using Amazon Mechanical Turk (MTurk), an online crowdsourcing platform, to obtain ratings from 330 laypeople. The same surveys were also distributed to 45 medical students.

MAIN OUTCOME MEASURE

Hypernasality was used as the primary speech outcome measure. Ordinal logistic regression was used to compare the ratings for each of the five scar quality categories with the patients' CAPS-A-AM hypernasality rating for both MTurk and medical student raters. Significance was set at α = 0.05.

RESULTS

For medical student ratings', ordinal logistic regression showed a statistically significant relationship between lip shortening (P=0.019) and overall appearance (P=0.044) with CAPS-A-AM hypernasality score, whereas the other scar categories showed no significant association. There was no statistically significant relationship between MTurk ratings and hypernasality for any of the scar categories.

CONCLUSIONS

The association found between lip shortening and overall scar appearance, thought by the authors to indicate scar contracture, and hypernasality, an indicator of VPI severity, provides an interesting insight into how to potentially identify patients who may be at increased risk for developing VPI.

The impact of surgical technique and cleft width on the rate of secondary surgery and velopharyngeal function in children with UCLP at 5 years of age

Several factors may influence speech outcome and the rate of secondary palatal surgery in patients with cleft palate. The aim of this study was to evaluate different types of intra-velar veloplasty within an otherwise uniform surgical protocol. The impact of cleft width and the surgeon's experience on outcome measurements was examined. This cross-sectional study included 62 individuals with unilateral cleft lip and palate born in 2000-2015. Based on the surgical technique used, they were divided into three groups. The cleft width was measured on dental casts. Blinded speech and language pathologists assessed velopharyngeal function with the composite score for velopharyngeal competence (VPC-Sum) for single words. They rated velopharyngeal function on a three-point scale (VPC-R) in sentences. Target consonants in words were phonetically transcribed. The percentage of correct consonants (PCC) was calculated. Surgical technique was not associated with any outcome. Cleft width was associated with the rate of secondary palatal surgery (OR 1.141, 95% CI 1.021-1.275, p = .020) and velopharyngeal insufficiency when using VPC-R (OR 2.700, 95% CI 1.053-6.919, p = .039) but not when using VPC-Sum (OR 1.985, 95% CI.845-4.662, p = .116). PCC was not associated with cleft width and did not differ between surgical techniques. Radical muscle dissection did not exhibit superiority over intra-velar veloplasty reinforced by the palatopharyngeal muscle. Follow-ups at later ages with larger groups will be necessary to evaluate and compare surgical techniques accurately. Cleft width had a greater impact on the rate of secondary surgery and velopharyngeal function than surgical technique, but neither affected the PCC.

Investigating the Impact of Additional Congenital Malformations on Speech Outcomes at age Five in Children with a Cleft Palate

OBJECTIVE

To determine whether children born with a cleft palate ± lip (CP ± L) and additional congenital differences (ACDs - including 'Congenital malformations and deformations' as coded in ICD-10), are less likely to meet the three national speech outcome standards at age five compared to children with CP ± L and no ACDs.

DESIGN

An observational study, utilizing national data from the UK Cleft Registry and Audit NEtwork (CRANE) Database linked to national administrative data of hospital admissions.

SETTING

National Health Service, England.

PATIENTS

2191 children (993 female, 1198 male) with CP ± L, born 2006-2012 in England, with complete speech data and consent to data linkage.

OUTCOME MEASURE

Perceptual speech analysis utilised the Cleft Audit Protocol for Speech - Augmented (CAPS-A) rating and United Kingdom National Speech Outcome Standards (Speech Standard 1 (SS1), Speech Standard 2a (SS2a) and Speech Standard 3 (SS3)).

RESULTS

Of 2191 children, 759 (35%) had at least one ACD. Presence of one ACD did not significantly impact speech outcomes but two or more ACDs reduced the odds of achieving all three speech standards: SS1 aOR 0.602 (CI 0.45-0.82, P = .002), SS2a aOR 0.563 (CI 0.41-0.77, P = .001), SS3 aOR 0.606 (0.43-0.84, P = .003). When exploring ACDs by ICD-10 groupings, congenital malformations of the 'Eye, ear, face and neck', 'Circulatory system', 'Digestive system', 'Musculoskeletal system' and 'Other congenital malformations' reduced a child's odds of achieving the speech standards.

CONCLUSIONS

ACDs, in the absence of a known syndrome, have a significant impact on speech outcome at age five. Incorporating these factors into risk-adjustment models for service level outcome reporting is recommended.

Early Cleft Palate Repair is Associated With Lower Incidence of Velopharyngeal Insufficiency Surgery

BACKGROUND

The timing of primary repair in nonsyndromic cleft palate remains controversial. Recent evidence suggests earlier repair is associated with a lower incidence of velopharyngeal insufficiency (VPI). The authors aim to evaluate these findings in a large cohort study using causal inference.

METHODS

All nonsyndromic cleft palate repairs in California were extracted between 2000 and 2021 from the California Health Care Access and Information (HCAI) database. Cases were linked with VPI surgery following cleft palate repair based on unique identifiers. The main outcome measure was incidence of VPI surgery evaluated with propensity score matching. Early cleft palate repair was defined as <7 months of age versus traditional cleft palate repair at >11 months of age. Standardized mean differences (SMD) were measured before and after matching for potential confounders including sex, race, payer, and distance from patient home to hospital.

RESULTS

In all, 52,007 cleft palate repairs were included, of which 12,169 (23.3%) were repaired early and 39,838 (76.7%) were repaired traditionally. Early cleft palate repairs underwent VPI surgery in 1.2% (13/1,000) of cases, compared with 6.1% (61/1000) in the traditional repair cohort. Post-matching, the average treatment effect of early repair was a 6.3% reduction in VPI surgery (P<0.001, 95% CI -6.3, -5.4%). All covariate SMDs were <|0.1| after matching.

CONCLUSION

Our cohort study demonstrates a significantly reduced incidence of VPI surgery in children with primary cleft palate repair <7 months of age. Craniofacial centers should consider early cleft palate repair in appropriate patients.

Exploring the relationship between cleft type and speech outcome in 4-to-6-year-olds with non-syndromic cleft palate using different measures: A preliminary report

Cleft type affects speech outcomes, but exact relationships remain unclear as outcome measures vary. The primary aim was to investigate the relationship between cleft type and speech outcome using different measures in 4-to-6-year-olds with non-syndromic clefts. Secondary aims were to explore the relationships between (i) speech measures used; and (ii) parent perception of speech intelligibility and listener familiarity. Twenty-two pre-schoolers with clefts, plus one parent for each child, were recruited through a hospital outpatient clinic. Children with cleft lip and palate (CLP; n = 11) and those with cleft palate only (CP; n  = 11), matched on age and time of palate repair, were compared on Percentage Consonants Correct (PCC), clinician-reported speech intelligibility, and parent rating on the Intelligibility-in-Context Scale (ICS). Children with CLP had significantly lower PCC scores than children with CP (p = .020), but had no significant differences in their clinician- or parent-reported speech intelligibility. Clinician-reported speech intelligibility correlated significantly with both PCC (τ = .594, p < 0.01) and ICS (τ = .424, p  = 0.009). No significant correlation was found between PCC and ICS (τ =.197, p = 0.113). Overall, parents rated their child's intelligibility higher for familiar compared to unfamiliar communication partners (τ  = 2.325, p = 0.001, r  = .76). Cleft type is crucial for intervention planning when objective measures are employed. Speech outcomes should be evaluated at impairment, activity, and participation levels, and by different communication partners, to comprehensively evaluate communicative effectiveness.

Should left- and right-sided unilateral cleft lip and palate patients be grouped together when reporting the outcomes?

OBJECTIVES

Investigate associations between cleft laterality in patients with non-syndromic unilateral cleft lip and palate (UCLP) and oral-health, dental-arch, speech, audiological, psychological and nasolabial-aesthetic outcomes.

METHODS

Secondary data analysis of the outcomes of 5-year-old children with non-syndromic complete UCLP identified from three studies: Cleft Collective (n = 155), Cleft Care UK (CCUK) (n = 266) and Clinical Standards Advisory Group (CSAG) study (n = 238). Outcome measures included occlusal assessment using the 5-year-old's index score, speech intelligibility rating using the CAPS-A Audit tool, audiological assessment using pure tone audiometry, nasolabial aesthetic assessment using the Asher-McDade tool, oral-health assessment using decayed, missing, filled teeth scores and parent-reported outcomes. Logistic regression with adjustment for age, sex and index-of-multiple-deprivation scores were performed.

RESULTS

No differences were found in patient-reported outcomes between the left and right clefts in the Cleft Collective study. From the CCUK study, right clefts had poorer speech (n = 236; 95% CI 1.09, 3.42; and P = .03) and hearing outcomes (n = 211; 95% CI 1.03, 3.43; P = .04). In the CSAG study, patients with left clefts were more likely to be teased (n = 213; 95% CI 0.26, 0.85; and P = .01).

CONCLUSION

Weak associations between cleft laterality, speech, hearing and psychological outcomes were found, however the findings were inconsistent across the studies. This study contributes to evidence of associations between laterality and outcomes in children born with UCLP.

Using "Real-World Data" to Study Cleft Lip/Palate Care: An Exploration of Speech Outcomes from a Multi-Center US Learning Health Network

OBJECTIVE

To assess the ability of a cleft-specific multi-site learning health network registry to describe variations in cleft outcomes by cleft phenotypes, ages, and treatment centers. Observed variations were assessed for coherence with prior study findings.

DESIGN

Cross-sectional analysis of prospectively collected data from 2019-2022.

SETTING

Six cleft treatment centers collected data systematically during routine clinic appointments according to a standardized protocol.

PARTICIPANTS

714 English-speaking children and adolescents with non-syndromic cleft lip/palate.

INTERVENTION

Routine multidisciplinary care and systematic outcomes measurement by cleft teams.

OUTCOME MEASURES

Speech outcomes included articulatory accuracy measured by Percent Consonants Correct (PCC), velopharyngeal function measured by Velopharyngeal Competence (VPC) Rating Scale (VPC-R), intelligibility measured by caregiver-reported Intelligibility in Context Scale (ICS), and two CLEFT-Q™ surveys, in which patients rate their own speech function and level of speech distress.

RESULTS

12year-olds exhibited high median PCC scores (91-100%), high frequency of velopharyngeal competency (62.50-100%), and high median Speech Function (80-91) relative to younger peers parsed by phenotype. Patients with bilateral cleft lip, alveolus, and palate reported low PCC scores (51-91%) relative to peers at some ages and low frequency of velopharyngeal competency (26.67%) at 5 years. ICS scores ranged from 3.93-5.0 for all ages and phenotypes. Speech Function and Speech Distress were similar across phenotypes.

CONCLUSIONS

This exploration of speech outcomes demonstrates the current ability of the cleft-specific registry to support cleft research efforts as a source of "real-world" data. Further work is focused on developing robust methodology for hypothesis-driven research and causal inference.

Articulating the issues: speech assessment and intervention in cleft lip and palate

This paper describes the impact of cleft lip and palate on speech. It provides an overview for the dental clinician of the key issues affecting speech development and clarity. The paper summarises the complex speech mechanism and cleft-related factors that affect speech, including palatal, dental and occlusal anomalies. It outlines the framework for speech assessment throughout the cleft pathway and provides a description of cleft speech disorder, as well as describing treatment approaches for cleft speech and velopharyngeal dysfunction.This is followed by a spotlight on speech prosthetics for treating nasal speech, with an emphasis on joint management by the Speech and Language Therapist and Consultant in Restorative Dentistry. This includes the core multidisciplinary approach, clinician and patient-reported outcome measures, and brief discussion of national developments in this area.The importance of multidisciplinary cleft care is highlighted and, within this, the essential interaction between speech and dental clinicians in providing routine care, as well as in delivering a highly specialist speech prosthetics service.

The relationship between auditory behaviours and speech and language development in children with cleft lip and palate

PURPOSE OF REVIEW

Children born with a cleft lip and palate (CLP) are at risk of speech problems. There is a high prevalence of conductive hearing loss due to otitis media with effusion and recent research has highlighted broader difficulties with language and educational attainment. There has been increased interest in the impact of auditory processing on a child's development, but little study into links between auditory skills and speech and language development.

RECENT FINDINGS

Children with CLP consistently struggle with auditory tasks. Difficulties processing words in a noisy background, auditory attention and temporal processing are frequently reported. A recent study in the United Kingdom investigated the auditory behaviours of 95 children aged 5-8 years with nonsyndromic CLP and compared these with speech and language profiles. Auditory difficulties correlated with speech development and most auditory behaviours correlated with language outcomes. There was also a correlation of language with speech outcomes, suggesting a more complex and interdependent relationship.

SUMMARY

Children with CLP present with high levels of difficulties with auditory skills. The potential impact of this on broader development needs further research, but clinicians should ensure that auditory skills beyond the hearing test are monitored, and advice given to parents to minimize the impact.

Scandcleft randomized trials of primary surgery for unilateral cleft lip and palate: Speech proficiency at 10 years of age

BACKGROUND & AIM

To assess consonant proficiency and velopharyngeal function in 10-year-old children born with unilateral cleft lip and palate (UCLP) within the Scandcleft project.

METHODS & PROCEDURES

Three parallel group, randomized, clinical trials were undertaken as an international multicentre study by nine cleft teams in five countries. Three different surgical protocols for primary palate repair (Arm B-Lip and soft palate closure at 3-4 months, hard palate closure at 36 months, Arm C-Lip closure at 3-4 months, hard and soft palate closure at 12 months, and Arm D-Lip closure at 3-4 months combined with a single-layer closure of the hard palate using a vomer flap, soft palate closure at 12 months) were tested against a common procedure (Arm A-Lip and soft palate closure at 3-4 months followed by hard palate closure at 12 months) in the total cohort of 431 children born with a non-syndromic UCLP. Speech audio and video recordings of 399 children were available and perceptually analysed. Percentage of consonants correct (PCC) from a naming test, an overall rating of velopharyngeal competence (VPC) (VPC-Rate), and a composite measure (VPC-Sum) were reported.

OUTCOMES & RESULTS

The mean levels of consonant proficiency (PCC score) in the trial arms were 86-92% and between 58% and 83% of the children had VPC (VPC-Sum). Only 50-73% of the participants had a consonant proficiency level with their peers. Girls performed better throughout. Long delay of the hard palate repair (Arm B) indicated lower PCC and simultaneous hard and soft palate closure higher (Arm C). However, the proportion of participants with primary VPC (not including velopharyngeal surgeries) was highest in Arm B (68%) and lowest in Arm C (47%).

CONCLUSIONS & IMPLICATIONS

The speech outcome in terms of PCC and VPC was low across the trials. The different protocols had their pros and cons and there is no obvious evidence to recommend any of the protocols as superior. Aspects other than primary surgical method, such as time after velopharyngeal surgery, surgical experience, hearing level, language difficulties and speech therapy, need to be thoroughly reviewed for a better understanding of what has affected speech outcome at 10 years.

WHAT THIS PAPER ADDS

What is already known on the subject Speech outcomes at 10 years of age in children treated for UCLP are sparse and contradictory. Previous studies have examined speech outcomes and the relationship with surgical intervention in 5-year-olds. What this study adds to the existing knowledge Speech outcomes based on standardized assessment in a large group of 10-year-old children born with UCLP and surgically treated according to different protocols are presented. While speech therapy had been provided, a large proportion of the children across treatment protocols still needed further speech therapy. What are the potential or actual clinical implications of this work? Aspects other than surgery and speech function might add to the understanding of what affects speech outcome. Effective speech therapy should be available for children in addition to primary surgical repair of the cleft and secondary surgeries if needed.