Psychometric findings and normative values for the CLEFT-Q based on 2434 children and young adult patients with cleft lip and/or palate from 12 countries

Translation, Validation, and Cultural Adaptation of CLEFT-Q© for use in Indonesia

OBJECTIVE

To translate and validate CLEFT-Q©, patient-reported outcome measure for patients with cleft lip and/or palate (CL and/or P), into Indonesian. CLEFT-Q© covers the domains of appearance, facial function, health-related quality of life and consists of scales describing outcomes after cleft surgery.

DESIGN

The CLEFT-Q© instrument was translated according to the International Society of Pharmacoeconomics and Outcomes Research guidelines, including translation, cognitive debriefing, and field-testing.

SETTING

Dr. Cipto Mangunkusumo Hospital, Indonesia; independent CL and/or P support groups.

PATIENTS

Patients ages 8-29 with a history of repaired CL and/or P were grouped based on age. Those unable to complete the questionnaire independently were excluded.

INTERVENTIONS

The primary objective was reliable translation of the CLEFT-Q® instrument. Each scale was assessed for its internal consistency (Cronbach's alpha) and validity (inter-item correlation), and sub-group analyses were performed based on age group.

RESULTS

Forward and back translation revealed 25(13.3%) and 12(6.3%) of items were difficult to translate. Cognitive debriefing revealed 10(5.3%) items were difficult to understand, with the lowest reliability on the facial appearance scale (α=0.27). Other scales demonstrated acceptable to excellent reliability (α=0.53-0.68). Field testing revealed acceptable reliability and validity of the translation (α = 0.74-0.92; 69% ideal range of inter-item correlation). Sub-group analyses revealed patients in the <11y.o. and >18y.o. groups had the lowest scores on the "cleft lip scar" scale while those 11-18y.o. had the lowest scores on the "nostrils" scale.

CONCLUSION

Iterative translation and cultural adaptation of CLEFT-Q© into Indonesian demonstrated reliability and validity of the tool, supported by acceptable to excellent internal consistency and ideal inter-item correlation.

Evaluation and recommendations of the oral health, oral function, and orofacial aesthetics-related measures of the ICHOM Standard Set for Cleft Lip and Palate

This study was performed to evaluate the efficacy of outcome measures for the orofacial domain included in the International Consortium for Health Outcomes Measurement Standard Set for Cleft Lip and Palate (ICHOM-SCS). In this multicentre study involving two cleft centres, suggestions to optimize the type and timing of outcome measures were made based on data and clinical experience. Patient-reported outcome measures (PROMs) (CLEFT-Q Jaw, Teeth, Eating/Drinking; Child Oral Health Impact Profile-Oral Symptoms Scale (COHIP-OSS)) and clinical outcome measures (caries experience and dental occlusion) data were collected retrospectively for age 5, 8, 10, 12, 19, and 22 years. The data were categorized by cleft type and analysed within and between age groups using Spearman correlation, the distribution of responses per item, a two-sample test for equality of proportions, and effect plots. Most correlations between PROMs and clinical outcome measures were weak (r < 0.5), suggesting PROMs and clinical outcome measures complement each other. The COHIP-OSS and CLEFT-Q Eating/Drinking barely detected problems in any patient category and are no longer recommended. A suitable alternative appears complex to find; outcomes of this study and the recent literature doubt an added value. Similar problems were found in the CLEFT-Q Jaw at time-point 12 years. Therefore, time-points 15 and 17 years are currently suggested.

Finnish Translation and Linguistic Validation of the CLEFT-Q Questionnaire

OBJECTIVE

Cleft lip and/or palate (CL/P) can have long-lasting effects on the appearance, function, and psychosocial wellbeing of patients. The CLEFT-Q questionnaire is a patient-reported outcomes instrument specifically designed to assess the health-related quality of life of patients with CL/P. The aim of this study was to produce and linguistically validate a Finnish version of the CLEFT-Q questionnaire.

DESIGN

The CLEFT-Q questionnaire was translated into Finnish following guidelines of the International Society for Pharmacoeconomics and Outcomes Research. Pilot testing with cognitive debriefing interviews was conducted on patients of the target age range of the questionnaire, 8-29, and with various cleft types.

RESULTS

The CLEFT-Q questionnaire translated readily into Finnish. A review of the backward translation led to two words being changed. Thirteen patients - ten females and three males - with a median age of 14 years, participated in the cognitive debriefing interviews. The interviews led to further nine word changes. The pilot study data suggested that the performance of the Finnish version of the instrument is in line with the original CLEFT-Q questionnaire.

CONCLUSIONS

The Finnish version of CLEFT-Q produced here is linguistically valid and ready for use in the evaluation of the health-related quality of life of patients with CL/P. However, future work is needed to further assess the validity and the reliability of the CLEFT-Q in the Finnish patient population.

Long-Term Functional Outcomes in Pediatric Head and Neck Cancer Patients: A Systematic Review

OBJECTIVE

The multimodal treatments for pediatric head and neck (H&N) malignancies can have significant long-term functional consequences for growing patients. This systematic review aims to analyze the current knowledge of functional outcomes for pediatric H&N cancer survivors.

DATA SOURCES

PubMed, Embase, Web of Science.

REVIEW METHODS

Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines were followed, and 1356 papers were reviewed by 3 team members with conflict resolution by a senior member.

RESULTS

Fourteen studies were included. Nine of 14 (64%) papers reported issues with swallowing, characterized as either dysphagia, odynophagia, oropharyngeal fibrosis, esophageal stenosis, xerostomia, trismus, or general issues with the throat and mouth. Six of 14 papers noted nutritional and feeding deficiencies, and 5 of 14 additionally noted issues with speech and voice changes. Four of 14 (29%) reported hearing impairments and/or loss. A majority of papers (9/14) reported long-term functional characteristics as a secondary outcome. Three of 14 (21%) reported a quality of life (QoL) measure. Heterogeneity in methodology and reporting precluded analysis of any relationship between treatment type and functional outcomes. Recommendations include integration of objective measures of feeding support and swallowing, as well as regular measurements of function and QoL parameters during treatment to better understand the evolution of QoL and function throughout care.

CONCLUSION

Relatively few studies focus on functional outcomes following the treatment of pediatric H&N cancer. Swallowing difficulty is the most frequently reported deficit, but objective data is rarely reported. Standardization of functional outcome assessment could improve the quality of evidence for pediatric patients treated for H&N cancer.

Self-perceived oral health and orofacial aesthetics of cleft patients

PURPOSE

To evaluate the self-perceived oral health and aesthetics of the dentition and jaw in patients with different types of oral cleft, measured by patient-reported outcome measures (PROMs). Additionally, to compare the results of the PROMs between cleft lip and or/palate (CL/P) patients and non-affected controls.

METHODS

420 CL/P patients treated at the cleft team of the Erasmus Medical Center, Rotterdam, The Netherlands, were included, and 138 non-cleft patients were recruited as control-group. Patient's perceptions were retrospectively evaluated using the CLEFT-Q Teeth for dental aesthetics at ages 8, 12 and 22, CLEFT-Q Jaw for jaw aesthetics at ages 12 and 22, and the Child Oral Health Impact Profile-Oral Symptoms Subscale (COHIP-OSS) for oral health at ages 8 and 12. One-way ANOVA was used to compare differences in oral health and aesthetic perceptions among age-groups, cleft types, as well as between cases and controls.

RESULTS

CL/P patients were significantly less satisfied than controls with their dental aesthetics (p = 0.001). CL/P patients reported significantly lower satisfaction on CLEFT-Q Teeth scores at ages 8 and 12, than at 22 years (p < 0.001). Patients with the most extensive cleft phenotype, Cleft Lip and Palate (CLAP), reported lowest satisfaction on the CLEFT-Q Teeth. No differences in perceptions of oral health nor in aesthetics of the jaw were found in the different cleft types, ages, nor in study versus control group.

CONCLUSION

This study found differences in self-perceived dental aesthetics: CL/P patients are less satisfied than non-affected controls. CLAP patients are least satisfied, but satisfaction increases with age.

Establishing Reliability and Validity of the FACE-Q Craniofacial Module for Pediatric Head and Neck Cancer

Purpose: We aimed to establish content validity and assess the psychometric properties of the FACE-Q Craniofacial Module, a patient-reported outcome measure, for use in pediatric and adolescent patients with head and neck cancer (HNC). Methods: To establish content validity (Part 1), between June 2017 and August 2019, cognitive interviews were conducted with survivors of pediatric HNC (n = 15), and input was obtained from clinical experts (n = 21). To examine item and scale performance (Part 2), Rasch Measurement Theory (RMT) analysis was performed using data from two international studies (n = 121). Results: Part 1: Qualitative data from 15 survivors and input from 21 experts provided evidence to support the use of the FACE-Q Craniofacial Module in pediatric HNC. Part 2: The field-test study sample included 121 survivors of pediatric HNC. RMT analysis provided evidence of reliability and validity for 10 FACE-Q scales. Data for each scale fit the RMT model. Scale reliability was high, with Person Separation Index and Cronbach's alpha values ≥0.82 for 9 scales. Mean scores on the Appearance, Psychological, and Social scales were higher for those who liked aspects of their face more. For participants with (vs. without) a facial difference, mean scores were lower for the Face, Jaws, Psychological, and Social scales. Conclusion: The FACE-Q Craniofacial Module evidenced reliability and validity for HNC survivors aged 8-29 years and can be used in research and clinical care to measure quality of life of pediatric survivors with HNC.

Psychosocial Status and Self-Perception in Patients with Cleft Lip and/or Palate

OBJECTIVE

To describe how the psychosocial status of patients with cleft lip and/or palate (CL/P) relates to patient-reported outcomes (PROs).

DESIGN

Cross-sectional retrospective chart review.

SETTING

Tertiary care pediatric hospital.

PATIENTS/PARTICIPANTS

Patients aged 8 to 29 years attending cleft team evaluations during a 1-year period.

MAIN OUTCOME MEASURES

CLEFT-Q.

RESULTS

Patients (N = 158) with isolated or syndromic CL/P and mean age 13.4 ± 3.0 years were included. Fifteen (9%) patients had siblings who also had CL/P. Of 104 patients who met with the team psychologist, psychosocial concerns were identified in 49 (47%) patients, including 25 (24%) with Attention-Deficit/Hyperactivity Disorder or behavior concerns, 28 (27%) with anxiety, and 14 (13%) with depression or mood concerns. Younger age and having siblings with cleft were associated with better PROs, while psychosocial concerns were associated with worse PROs on Speech, Psychosocial, and Face Appearance scales.

CONCLUSIONS

Patient perception of cleft outcomes is linked to psychosocial factors.

Thai CLEFT-Q: Phase 1-A Pilot Study of Translation and Cultural Adaptation in Thailand

To translate and culturally adapt the original English version of the CLEFT-Q into Thai (Thai CLEFT-Q).

A pilot study.

A single tertiary referral hospital in Thailand.

Patients with cleft lip or palate (CL/P) aged between 8 and 29 years.

The CLEFT-Q was translated and culturally adapted from English into Thai using the good practice guidelines developed by the International Society for Pharmacoeconomics and Outcomes Research (ISPOR). Two forward translations and reconciliation, 1 back translation, and 2 sets of cognitive debriefing interviews with patients were performed to develop the Thai CLEFT-Q.

The English version of the CLEFT-Q consists of 13 scales (119 items) assessing appearance, health-related quality of life (HRQOL), and facial function. The forward translations revealed 33.6% inconsistencies. They were related to narrow meaning (2.5%) and improper (16.8%) or incorrect (14.3%) wording or phrasing of the items. After reconciliation, the back translation showed 5 inconsistencies (4.2%) with the original version. However, no changes were needed because the reconciliation version was consistent with the source version. Sixteen participants underwent cognitive debriefing interviews, which revealed a comprehensive interpretation of the Thai CLEFT-Q. Interim reports revealed fair facial appearance scores, albeit with HRQOL and facial function outcomes.

Translation and cultural adaptation of the Thai CLEFT-Q provided evidence of its transferability and equivalence with the original English version. Feasible comprehension of the Thai version was also achieved.

Psychological and Peer Difficulties of Children with Cleft Lip and/or Palate: A Systematic Review and Meta-Analysis

OBJECTIVES

A systematic review and meta-analysis were conducted to determine if children born with cleft lip and/or palate are at increased risk of psychological and peer difficulties, and if so, which difficulties they develop.

METHODS

EMBASE, MEDLINE, and PsycINFO were searched for English language studies published between January 2005 and January 2022 which investigated the psychological outcomes and peer function of children with nonsyndromic cleft lip and palate. Outcomes included internalizing problems, such as anxiety and depression, externalizing problems, such as hyperactivity, conduct disorders, self-concept including self-image and self-esteem, peer problems, resilience, coping, and overall psychological function. A risk of bias assessment was performed using the Newcastle-Ottawa Scale. Random effects models were used in the meta-analysis to compare the outcomes for children born with a cleft and those without.

RESULTS

In total 41 studies met inclusion criteria, with 9 included in the meta-analysis. Children born with a cleft appear to have similar psychological outcomes compared to normative controls when using the strengths and difficulties questionnaire. There are some minor differences between self-report and parent report, with parents generally reporting that their child with a cleft has increased emotional, conduct, and hyperactivity problems. The small differences between the study cohort and control cohorts are unlikely to imply any differences on a clinical level.

CONCLUSIONS

Overall psychological outcomes appear to be similar between children born with a cleft and the nonaffected population, however, some symptoms such as anxiety and depression appear higher in children with cleft lip and/or palate.

Screening for Academic Risk Among Students With Cleft Lip and/or Palate: Patterns of Risk and Qualities of Effective Tools

This study evaluated the effectiveness of academic screening measures in relation to parent-reported diagnoses.

Multicenter, retrospective cohort study including structured interviews, questionnaires, and chart reviews.

Six North American cleft centers.

Children (n = 391) with cleft lip and/or palate, ages 8 to 10 years of age (192 male) and their guardians were recruited during regular clinic visits.

Parent and child ratings on the Pediatric Quality of Life Inventory (PedsQL) School Scale, child report on CleftQ School Scale, parent report on the Adaptive Behavior Assessment System-Third Edition Functional Academics (ABAS-FA) Scale and Child Behavior Checklist (CBCL) School Competency Scale, parent interview, and medical chart review.

Risk for concerns ranged from 12% to 41%, with higher risk reflected on the CBCL-SC compared to other measures. Males with cleft palate were consistently at the highest risk. Only 9% of the sample had a parent-reported diagnosis of a learning or language disability. Ratings from the ABAS-FA and CBCL-SC had the highest utility in identifying those with language and/or learning concerns.

As cleft teams work to develop standardized batteries for screening and monitoring of patients, it is important to evaluate the effectiveness of measures in identifying those at highest risk. When screening for language and learning disorders, questions related to potential academic struggles, such as increased school effort or increased school distress, are most useful. Referrals for follow-up evaluation are recommended for those identified at high risk.

Most Efficient and Meaningful Patient-Reported Appearance Assessment in Different Cleft Types and Age Groups with CLEFT-Q

BACKGROUND

The CLEFT-Q, a questionnaire developed and validated specifically for cleft patients, contains seven appearance scales. The International Consortium of Health Outcomes Measurement (ICHOM) has incorporated only some CLEFT-Q appearance scales in the Standard Set to minimize burden. This study evaluates which appearance scales provide the most meaningful information in the different cleft types at specific ages, for the most efficient cleft appearance outcome assessment.

METHODS

Within this international multicenter study, outcomes of the seven appearance scales were collected, either as part of the ICHOM Standard Set, or as part of the field test study performed to validate the CLEFT-Q. Analyses were performed in separate age groups and cleft types, and involved univariate regression analyses, trend analyses, t tests, correlations, and floor and ceiling effects.

RESULTS

A total of 3116 patients were included. Scores for most appearance scales showed a downward trend by age group, with the exception of the Teeth and Jaw scales. In all cleft types, several scales correlated strongly with each other. No floor effects were observed, but ceiling effects were found in several scales in different age groups, most often in the CLEFT-Q Jaw scale.

CONCLUSIONS

A proposition for the most meaningful and efficient appearance outcome assessment in cleft patients is made. It was composed so that recommendations are of value for different cleft protocols and initiatives. Suggestions for the use of scales in the ICHOM Standard Set at different ages are given, and also from a clinical perspective. Use of the CLEFT-Q Scar, Lips, and Nose scales will provide additional relevant information.

What is the optimal assessment of speech? A multicentre, international evaluation of speech assessment in 2500 patients with a cleft

OBJECTIVES

Speech problems in patients with a cleft palate are often complex and multifactorial. Finding the optimal way of monitoring these problems is challenging. The International Consortium of Health Outcomes Measurement (ICHOM) has developed a set of standardised outcome measures at specific ages for patients with a cleft lip and/or palate, including measures of speech assessment. This study evaluates the type and timing of speech outcome measures currently included in this ICHOM Standard Set. Additionally, speech assessments in other cleft protocols and initiatives are discussed.

DESIGN, SETTING AND PARTICIPANTS

An international, multicentre study was set up including centres from the USA and the Netherlands. Outcomes of clinical measures and Patient Reported Outcome Measures (PROMs) were collected retrospectively according to the ICHOM set. PROM data from a field test of the CLEFT-Q, a questionnaire developed and validated for patients with a cleft, were collected, including participants from countries with all sorts of income statuses, to examine the value of additional moments of measurement that are used in other cleft initiatives.Data from 2500 patients were included. Measured outcomes contained univariate regression analyses, trend analyses, t-tests, correlations and floor and ceiling effects.

RESULTS

PROMs correlated low to moderate with clinical outcome measures. Clinical outcome measures correlated low to moderate with each other too. In contrast, two CLEFT-Q Scales correlated strongly with each other. All PROMs and the Percent Consonants Correct (PCC) showed an effect of age. In patients with an isolated cleft palate, a ceiling effect was found in the Intelligibility in Context Scale.

CONCLUSION

Recommendations for an optimal speech outcome assessment in cleft patients are made. Measurement moments of different cleft protocols and initiatives are considered in this proposition. Concerning the type of measures, adjustment of the current PCC score outcome seems appropriate. For centres with adequate resources and specific interest in research, translation and validation of an upcoming tool, the Cleft Audit Protocol for Speech Augmented, is recommended.

Treatment Outcomes of Interdisciplinary Care on Speech and Health-Related Quality of Life Outcomes in Adults With Cleft Palate

PURPOSE

Individuals born with a cleft palate with or without a cleft lip (CP ± L) often experience functional, aesthetic, and psychosocial consequences well into adulthood. This study aimed to investigate outcomes of speech and health-related quality of life (HRQoL) in adults with a CP ± L who received interdisciplinary cleft care at the Ghent University Hospital using valid, reliable, and condition-specific instruments.

METHOD

Thirteen Belgian Dutch-speaking participants with a CP ± L with a mean age of 25.4 years (SD = 5.1, range: 20-33 years) and an age- and gender-matched control group of 13 participants without a CP ± L with a mean age of 25.2 years (SD = 4.8, range: 20-32 years) were included in this study. Speech characteristics were evaluated perceptually and instrumentally. HRQoL was assessed through standardized patient-reported outcome measures. Outcomes were compared with those of the control group and to normative data where available.

RESULTS

Participants with a CP ± L in this sample demonstrated significantly lower speech acceptability (p < .001) and higher rates of hypernasality (p = .015) and nasal turbulence (p = .005) than the control group. They showed significantly higher satisfaction with appearance of the cleft scar compared with norms of adults with a CP ± L (p = .047). No other differences in speech characteristics, sociodemographics, or HRQoL were found between participants with and without a CP ± L.

CONCLUSIONS

The reduced speech acceptability and the presence of resonance and nasal airflow disorders may indicate the need for standardized long-term outcome measurement and interdisciplinary follow-up for speech characteristics and velopharyngeal insufficiency in young and middle adulthood in future clinical practice. Additional research is necessary to further substantiate these findings and to determine predictors for these continuing complications in adults with a CP ± L.

SUPPLEMENTAL MATERIAL

https://doi.org/10.23641/asha.24243901.

Establishment of a condition-specific quality-of-life questionnaire for children born with esophageal atresia aged 2-7 across 14 countries

Background

Esophageal atresia (EA) is a rare congenital anomaly characterized by a discontinuity of the esophagus. Following surgical repair, survival rates have improved dramatically the past decenniums and today exceed 90%, but the children commonly present with esophageal and respiratory morbidity. In 2018, a condition-specific quality-of-life questionnaire for children with esophageal atresia (EA) aged 2-7 in Sweden-Germany was finalized (The EA-QOL questionnaire). The study aim was to describe the evaluation of the new translations across 12 new countries in Europe, Asia, Africa, Central-and North America.

Methods

Following forward-backward translation into the new languages, the 17-item EA-QOL questionnaire was tested in cognitive debriefing interviews with parents of children with EA aged 2-7. Parents rated if each item was easy to understand (clarity) and sensitive to answer (interference with personal integrity). They could skip responding to a non-applicable/problematic item and give open comments. Predefined psychometric criteria were used; item clarity ≥80%/item sensitive to answer ≤20%/item feasibility ≤5% missing item responses. The decision to modify the translation was based on native expert, patient stakeholder, and instrument developer review, and the need for harmonization between translations.

Results

Similar to findings in the Swedish-German cognitive debriefing, the cross-cultural analysis of input from 116 parents from 12 new countries (4-14 parents, median 9 parents/country) showed that all items in the EA-QOL questionnaire fulfilled the criteria for item clarity ≥80% and sensitive to answer (ranging from 1%-4.5%), although results varied between countries. Four items had missing responses between 5.2% and 13.4%, three within the same domain and were in line with parents' explanations. Poor translations and feasibility were improved.

Conclusions

Based on parent input, the collaboration between native experts, patient stakeholders, and instrument developers, a linguistic version of the EA-QOL questionnaire for children aged 2-7 for use in and across 14 countries has been established. These efforts have set the conditions for a cross-cultural field test of the EA-QOL questionnaire and will open the doors for a new chapter in outcome research, registries, and clinical practice concerning children with EA. In the long-term, this will help increase knowledge of the disease's burden, promote patient-centeredness, exchange of information between nations, and strengthen evidence-based treatments for children born with EA.

Long-Term Patient-Reported Outcomes in Internationally Adopted Children with Cleft Lip and Palate

OBJECTIVE

To compare patient-reported outcomes (PROs) in internationally adopted patients with cleft lip and palate to those in non-adopted peers.

DESIGN

Cross-sectional study.

SETTING

Multidisciplinary cleft team at tertiary care hospital.

PATIENTS

Patients aged ≥ 8 with cleft lip and palate attending routine cleft team evaluations September 2021 - September 2022.

MAIN OUTCOME MEASURE

CLEFT-Q PRO scores.

RESULTS

Sixty-four internationally adopted patients and 113 non-adopted patients with a mean age of 13 years were included. Compared to non-adopted peers, adopted patients demonstrated worse satisfaction with face appearance (mean 59 vs. 66, p = .044), speech function (mean 69 vs. 78, p = .005), and speech distress (mean 80 vs. 84, p = .032). No significant differences were observed on the nose, nostrils, teeth, lips, lip scar, jaws, psychological function, or social function scales (p > .05). Objective clinical evaluation corroborated these findings, with adopted patients demonstrating worse Pittsburgh Weighted Speech scores (mean 3.0 vs 1.9, p = .027) and greater incidence of articulation errors (64% vs 46%, p = .021). No significant differences were observed in rates of mood, anxiety, or behavior concerns identified on psychosocial assessment (p = .764). Among adopted patients, undergoing palatoplasty prior to adoption was associated with worse satisfaction with speech, appearance, school, and social function (p < .05).

CONCLUSIONS

Patient-reported outcomes among internationally adopted adolescents and young adults with cleft lip and palate show slightly lower satisfaction with facial appearance and speech but otherwise demonstrate similar results to non-adopted peers on most appearance and psychosocial measures. PRO data correlated well with objective speech assessment and did not portend worse psychosocial function.

Psychosocial Outcomes in Children with Cleft Lip and/or Palate: Associations of Demographic, Cleft Morphologic, and Treatment-Related Variables

OBJECTIVE

To determine associations of demographic, morphologic, and treatment protocol parameters with quality of life (QoL), appearance/speech satisfaction, and psychological adjustment.

DESIGN

Observational study utilizing retrospective report of protocol variables and current outcome variables.

SETTING

Six North American cleft treatment clinics.

PARTICIPANTS

Children, ages 8.0-10.99 years, with Cleft Lip ± Alveolus, Cleft Palate, Cleft Lip and Palate, and parents (N = 284).

OUTCOME MEASURES

Pediatric QoL Inventory (PedsQL): Parent, Child, Family Impact Module (FIM); Patient Reported Outcome Measurement Information System (PROMIS); Child Behavior Checklist (CBCL); CLEFT-Q.

RESULTS

Outcome scores were average with few differences by cleft type. Multiple regression analyses yielded significant associations (Ps < .05) between socioeconomic status, race, and age at assessment and parent- and self-reported measures. Females had higher PROMIS Depression (β=.20) but lower CBCL Affective (β = -.16) and PROMIS Stigma scores (β= -.24). Incomplete cleft lip was associated with lower PROMIS Depression, and more positive ratings of CLEFT-Q: Nose, Nostril, Lip Scar; CBCL Competence scores, (βs = -.17 to .17). Younger Age at Lip Closure was associated with higher CBCL School Competence (β= -.18). Younger Age at Palate Closure was associated with higher Child PedsQL Total, Physical, Psychosocial QoL, and better CLEFT-Q Speech Function (βs = -.18 to -.15). Furlow Palatoplasty was associated with more CBCL Externalizing Problems (β = .17) higher CBCL Activities (β = .16). For all diagnoses, fewer Total Cleft-Related Surgeries was associated with lower PROMIS Stigma and higher CBCL Total Competence and Activities (βs = -.16 to .15).

CONCLUSIONS

Demographic characteristics, lip morphology, and treatment variables are related to later psychological functioning.

Quality of Life After Orthognathic Surgery in Patients with Cleft: An Overview of Available Patient-Reported Outcome Measures

Measuring the impact of orthognathic surgery on quality of life is of significant importance in patients with cleft deformities. Standardized tools such as patient-reported outcome measures (PROMs) are needed to fully comprehend patients' needs and perceptions. Therefore, the availability of reliable, valid, and comprehensive questionnaires for patients is essential. The aim of this study is to identify PROMs measuring the impact of orthognathic surgery on quality of life in patients with cleft deformities and to evaluate the identified PROMs.

A systematic search of the literature was performed according to the preferred reporting items for systematic reviews and meta-analysis guidelines. All validated PROMs, regarding the impact of orthognathic surgery on quality of life in patients with cleft deformities, were identified and assessed according to the quality criteria proposed for measurement properties of health status questionnaires.

An electronic search yielded 577 articles. After a full-text review of 87 articles, 4 articles met the inclusion criteria, comprising 58 PROMs. Of these 58 PROMs, 1 PROM (the CLEFT-Q) has been validated to measure the impact of orthognathic surgery on patients with a facial cleft. Evaluation of methodological quality of the included articles and assessment of the measurement properties of the CLEFT-Q show that the CLEFT-Q scores relatively good for all available measurement properties, making it suitable for immediate use.

The CLEFT-Q was found to be the only valid instrument so far to measure the impact of orthognathic surgery on the quality of life in patients with cleft deformities.

A Prospective Study to Examine Responsiveness and Minimally Important Differences (MIDs) for the CLEFT-Q Scales Following Three Cleft-Specific Operations

The aim of this study was to examine internal responsiveness and estimate minimally important differences (MIDs) for CLEFT-Q scales.

In this prospective cohort study, participants completed the CLEFT-Q appearance and health-related quality of life (HRQL) scales before and six months after cleft-related surgery.

Seven cleft centres in Canada, USA and UK participated.

Patients were ages 8-29 years with CL/P.

Patients underwent rhinoplasty, orthognathic or cleft lip scar revision surgery.

Internal responsiveness was examined using Cohen's d effect sizes (ESs) based on the following interpretation: 0.20-0.49 small, 0.50-0.79 moderate and ≥ 0.80 large. MIDs were estimated using two distribution-based approaches.

Participants had a rhinoplasty (n = 31), orthognathic (n = 21) or cleft lip scar revision (n = 18) surgery. Most participants were males (56%) and aged 8-11 years (41%). Following rhinoplasty, ESs were larger for the nose (0.92, p = 0.001) and nostrils (0.94, p < 0.001) scales than for the face scale (0.51, p = 0.003). MIDs ranged between 6.2-10.4. For orthognathic surgery, larger ES was observed for the jaws scale (1.80, p < 0.001) compared with the teeth (1.16, p < 0.001), face (1.15, p = 0.001) and lips (0.94, p < 0.001) scales. MIDs ranged between 5.9-14.4. In the cleft lip scar revision sample, the largest ES was observed for the nose scale (0.76, p = 0.03), followed by lips (0.58, p = 0.009) and cleft lip scar (0.50, p = 0.043) scales. MIDs ranged between 6.4-12.3.

CLEFT-Q detected change in key outcomes for three cleft-specific surgeries, providing evidence of its responsiveness. Estimated MIDs will aid in interpreting this PROM.

Psychometric Validation of the CLEFT-Q Patient Reported Outcome Measure: A Prospective Study to Examine Cross-Sectional Construct Validity

OBJECTIVE

CLEFT-Q is a condition-specific patient-reported outcome measure (PROM) for patients with cleft lip and/or palate (CL/P). The aim of this study was to examine the cross-sectional construct validity of the CLEFT-Q scales.

DESIGN

Construct validity was assessed through a prospective study that tested hypotheses regarding correlations of scores with other PROMs that measure related constructs.

SETTING

Seven cleft centres in Canada, the USA, and UK were involved.

PATIENTS/PARTICIPANTS

Patients were aged eight to 29 years with CL/P.

INTERVENTIONS

Before undergoing rhinoplasty, orthognathic, cleft lip scar revision, and alveolar bone graft, participants were asked to complete the following PROMs: CLEFT-Q (9 scales), Child Oral Health Impact Profile (socio-emotional subscale) and Cleft Hearing Appearance and Speech Questionnaire (features 1 subscale).

MAIN OUTCOME MEASURE(S)

The correlation coefficients examining the relationship between the scales were the main outcome measures. Correlations (Spearman) were calculated and interpreted as follows: <0.3 weak, 0.30 to 0.50 moderate, ≥0.50 strong.

RESULTS

Participants (n = 177) were mostly male (61%) and aged between eight and 11 years (42%). Overall, 38 of 52 (73%) hypotheses tested were supported. More specifically, 20 of 26 (77%) hypotheses about correlations between the appearance scales were supported, two of three (67%) hypotheses about correlations between the health-related quality of life scales were supported, and 16 of 23 (70%) hypotheses about correlations between the appearance and health-related quality of life scales were supported.

CONCLUSIONS

Cross-sectional construct validity of the CLEFT-Q scales adds further evidence of the psychometric properties of this instrument.

Optimizing the Psychosocial Function Measures in the International Consortium for Health Outcomes Measurement Standard Set for Cleft

BACKGROUND

To ensure the feasibility of implementing PROMs in clinical practice, they must be continually appraised for undue burden placed on patients and clinicians and their usefulness for decision-making. This study assesses correlations between the CLEFT-Q psychosocial scales in the International Consortium for Health Outcomes Measurement Standard Set for cleft and explores their associations with patient characteristics and psychosocial care referral.

METHODS

Spearman correlation coefficients were calculated for CLEFT-Q psychological function, social function, school function, face, speech function, and speech-related distress scales. Logistic regressions were used to assess the association of cleft phenotype, syndrome, sex, and adoption status on scale scores and clinical referral to psychosocial care for further evaluation and management.

RESULTS

Data were obtained from 3067 patients with cleft lip and/or palate at three centers. Strong correlations were observed between social function and psychological function (r > 0.69) and school function (r > 0.78) scales. Correlation between school function and psychological function scales was lower (r = 0.59 to 0.68). Genetic syndrome (OR, 2.37; 95% CI, 1.04 to 5.41), psychological function (OR, 0.92; 95% CI, 0.88 to 0.97), school function (OR, 0.94; 95% CI, 0.90 to 0.98), and face (OR, 0.96; 95% CI, 0.94 to 0.98) were significant predictors for referral to psychosocial care.

CONCLUSIONS

Because social function as measured by the CLEFT-Q showed strong correlations with both school and psychological function, its additional value for measuring psychosocial function within the Standard Set is limited, and it is reasonable to consider removing this scale from the International Consortium for Health Outcomes Measurement Standard Set for cleft.

Patient-reported outcomes in childhood head and neck rhabdomyosarcoma survivors and their relation to physician-graded adverse events-A multicenter study using the FACE-Q Craniofacial module

INTRODUCTION

Adverse events (AE) of treatment are prevalent and diverse in head and neck rhabdomyosarcoma (HNRMS) survivors. These AEs are often reported by physicians; however, patients' perceptions of specific AE are not well known. In this study, we explored patient-reported outcomes measuring appearance, health-related quality of life (HRQOL), and facial function in HNRMS survivors. Second, we assess the relationship between physician grading of AE and patient reporting.

MATERIALS AND METHODS

Survivors of pediatric HNRMS, diagnosed between 1993 and 2017, who were at least 2 years after completing treatment were invited to an outpatient clinic as part of a multicenter cross-sectional cohort study. At the outpatient clinics, survivors aged ≥8 years filled out the FACE-Q Craniofacial module; a patient-reported outcome instrument measuring issues specific to patients with facial differences. AE were systematically assessed by a multidisciplinary team based on the Common Terminology Criteria of Adverse Events system.

RESULTS

Seventy-seven survivors with a median age of 16 years (range 8-43) and median follow-up of 10 years (range 2-42) completed the questionnaire and were screened for AEs. Patient-reported outcomes varied widely between survivors. Many survivors reported negative consequences: 82% on appearance items, 81% on HRQOL items, and 38% on facial function items. There was a weak correlation between physician-scored AEs and the majority of patient-reported outcomes specific for those AEs.

CONCLUSIONS

Physician-graded AEs are not sufficient to provide tailored care for HNMRS survivors. Findings from this study highlight the importance of incorporating patient-reported outcome measures in survivorship follow-up.

HOW PRO'S CAN CONTRIBUTE TO WHAT MATTERS MOST TO PATIENTS WITH OROFACIAL CLEFTS

An orofacial cleft (OC) is a congenital cleft that may affect the lip, alveolus, hard and soft palate. An OC impacts the individuals' appearance, psychosocial well-being and causes functional problems including feeding, dentition, growth of jaws, hearing and speech. The treatment of an orofacial cleft usually reaches from birth until 22 years of age or later. To understand and listen in an objective manner, OC specific Patient reported Outcome (PRO) and experience (PRE) measures are imperative. In patients with OCs many shared decision making moments exist from birth until adulthood. The aim is to understand what knowledge exists on PROs and PREs in patients with OCs, to formulate challenges to improve care to OC patients and how research on OCs needs to adapt. PROs and PREs need to be tailored to the individual with an OC. A framework with specific OC key domains including appearance, facial function and Health related Quality of Life exists. The current framework does not include the social network around the OC patients yet. However attention should be put on including family and community support into the framework. Also at an individual level more attention should be paid to enhancing experiences compared to impeding experiences. To create a better understanding traditional indicators and outcomes are combined with PROMs in a structured way. Challenges were identified that seek to improve our complete set of (PRO and PRE) instruments to provide better care to the individual with an OC and provide a voice so that good shared decision making is enabled. Thereby the individual with an OC is further empowered.

Adult Cleft Patients: An Exploration of Functional Needs and Treatment Barriers

BACKGROUND

Management of cleft lip and palate has been well characterized in pediatric patients, but limited data exist regarding the long-term functional outcomes of cleft patients once they reach adulthood.

MATERIALS AND METHODS

An institutional, cross-sectional survey of adult patients with a history of cleft lip and/or palate was performed. The survey recorded patient characteristics, concerns, and barriers to care. Patient-reported outcome measures were assessed using the Nasal Obstruction Symptom Evaluation Scale, Epworth Sleepiness Scale, Mandibular Function Impairment Questionnaire, and the CLEFT-Q Speech Modules.

RESULTS

A total of 63 patients (18.2%) participated in the survey. The mean patient age was 43.7 years (median: 41 y, range: 19-93 y), and the most common diagnosis was cleft lip and palate (51%) followed by isolated cleft palate (35%) and isolated cleft lip (14%). A subset of patients scored with moderate to severe dysfunction on each outcome measure including the Nasal Obstruction Symptom Evaluation Instrument (59%), Epworth Sleepiness Scale (7%), and Mandibular Function Impairment Questionnaire (13%). Respondent scores on the CLEFT-Q Speech modules demonstrated a bimodal distribution with lower scores in a significant subset of patients with cleft palate and cleft lip and palate. Many respondents (41%) were interested in clinical evaluation but cited barriers to seeking treatment including financial barriers (35%) or lack awareness of clinical options (27%).

CONCLUSIONS

Many cleft patients have persistent needs or concerns in adulthood, especially regarding speech and nasal breathing. Systemic barriers pose challenges to these patients undergoing clinical evaluation.

The association between problematic smartphone use and the severity of temporomandibular disorders: A cross-sectional study

Objective

To evaluate the prevalence of different types of temporomandibular disorders (TMD) symptoms in young adults and determine their associations with problematic smartphone use (PSU).

Methods

The data of the study were collected from local university students through an online questionnaire survey. Demographic information, Fonseca Anamnestic Index (FAI), Smartphone Addiction Scale-Short Version (SAS-SV), and Patient Health Questionnaire-4 (PHQ-4) responses were gathered electronically and analyzed using multiple logistic regression analysis.

Results

There were 163 male and 307 female respondents were participated in this study. The prevalence of PSU and TMD were 83.6% and 66.4%, respectively. There was a moderate statistical correlation between PSU and TMD among young adults (r = 0.31, p < 0.01). The logistic regression model revealed that the risk of TMD was 1.77 times higher in people with PSU than in those without PSU (OR = 1.77; 95% CI 1.04-3.06). PSU is a risk factor for pain-related TMD (OR = 1.81; 95% CI 1.08-3.04) but not intra-articular TMD.

Conclusion

Subjects showed high prevalence of both TMD and PSU. People with PSU experienced more severe and frequent pain-related rather than intra-articular TMD symptoms than those without PSU. By reducing the problematic smartphone use, the risk factor of TMD might be avoided.

The cleft Q as an outcome measure after palatoplasty

The Cleft Q, a patient-reported outcome measure, has been adopted by the International Consortium for Health Outcome measurement as a valid tool for the measurement of outcomes following intervention on a patient with a cleft. It is scarcely used in sub-Saharan Africa. We report our first experience with the Cleft Q in measuring the outcomes following palatoplasty in an African adult female with a Veau type II defect. The Cleft Q was able to demonstrate improved scores across all domains measured. There is however a need for further validation of the Cleft Q in our setting.

Do Specific Craniomaxillofacial Features Correlate with Psychological Distress in Adult Pretreatment Orthodontic Patients? A Cephalometric Study

Purpose

To explore the relationship between craniomaxillofacial features and psychological distress among adult pretreatment orthodontic patients.

Methods

A group of 190 patients (95 males and 95 females) was included. Questionnaires including the Kessler psychological distress scale (K10) were sent to patients, and cephalograms were collected. Patients were divided into two groups according to K10 score: psychological distress group (score ≥ 20) and no psychological distress group (score < 20). Nineteen hard tissue and thirteen soft tissue parameters were traced on cephalograms to characterize the craniomaxillofacial features.

Results

There was no significant difference in gender or age distribution between the two groups. Male patients with psychological distress showed statistically significantly larger anterior facial height (AFH) (126.62 mm vs. 120.97 mm), upper lip length (25.11 mm vs. 23.26 mm), and smaller overbite (1.21 mm vs. 2.75 mm) than patients without psychological distress. Male patients with hyperdivergent pattern and open bite were more likely to have psychological distress. None of the parameters showed statistical differences across groups in females. Frankfort-mandibular plane angle (r = 0.235), Bjork's sum (r = 0.311), AFH (r = 0.322), overbite (r = −0.238), AFH/posterior facial height (r = 0.251), and upper anterior facial height (UAFH)/lower anterior facial height (LAFH) (r = −0.230) were correlated with K10 score in males. After adjusting gender and age, the AFH (B = 0.147) and UAFH/LAFH (B = −14.923) were significantly related with the K10 score.

Conclusion

Psychological distress was mainly correlated with hyperdivergent pattern, open bite, and larger lower anterior facial height proportion in pretreatment orthodontic patients. Orthodontists should be aware of the possible underlying psychological distress in patients with specific craniomaxillofacial features. Clinical assessment of psychological distress may need to take into account gender differences in patients.

Protocol for SonoSpeech Cleft Pilot: a mixed-methods pilot randomized control trial of ultrasound visual biofeedback versus standard intervention for children with cleft lip and palate

Background

Children with cleft lip and palate can continue to have problems producing clear speech after surgery. This can lead to social, emotional, and educational challenges. Typical treatment involves teaching children the correct tongue movements to produce speech sounds. This is known as articulation intervention. However, this intervention is challenging because the tongue is hidden from view and movements are difficult to see and describe. This pilot randomized control trial will try a new treatment, ultrasound visual biofeedback (U-VBF) versus standard articulatory intervention for children with cleft lip and palate, as comparison. Feasibility outcomes will be determined.

Methods/design

The Sonospeech project will enroll up to 40 children with cleft lip and palate aged 4;6 to 16 in a mixed-methods randomized controlled trial with blinded assessors. Children will receive either six sessions of U-VBF or articulation intervention. The primary goals of this pilot are to assess the feasibility and inform the design of a full-scale RCT of U-VBF for children with cleft speech characteristics. This will be achieved by determining the following outcome measures: recruitment/attrition rates; measures of pre-post follow-up completion; and acceptability of the randomization and interventions to families.

Discussion

Larger trials of speech interventions for children with cleft lip and palate are needed. This pilot/feasibility study will determine whether a larger randomized control trial comparing ultrasound and articulation interventions is feasible.

Trial registration

ISRCTN, ISRCTN17441953. Registered 22 March 2021. See Table 2 in Appendix 1 for all items.

The Cleft-screen-questionnaire (CSQ) - A validated screening instrument for health-related quality of life in cleft patients

BACKGROUND

The objective of this study is to develop and validate a specific screening instrument for assessing the quality of life (QoL) of patients with orofacial clefts. The Cleft-Screen-Questionnaire (CSQ) aims at identifying the main problematic areas and is intended for the routine use in everyday clinical practice to constantly evaluate the conditions' and treatments' effects on patients' well-being.

METHODS

First, a pool of 58 questions is created by collecting items from validated questionnaires previously used for assessing the QoL in cleft populations. After the removal of duplicate questions, the questionnaires are answered by 152 patients from a tertiary care center. A factor analysis followed by the calculation of Cronbach's alpha as a reliability measurement led to the final CSQ presented here.

RESULTS

The applied factor analysis resulted in five factors. Items showing low factor loadings (seen as <0.5) were excluded initially. Accordingly, factor analysis led to a preliminary number of 43 items. A reliability analysis using Cronbach's alpha and corrected alpha if item deleted showed an overall moderate to high reliability (seen as: 0.6-0.9). After excluding questions with increasing alphas if item deleted, analyses yielded in a final number of 38 questions.

CONCLUSION

The final 38-item CSQ is a reliable instrument for evaluating the health-related QoL of cleft patients.

The Impact of Fan-Type Rapid Palatal Expanders on Speech in Patients With Unilateral Cleft Lip and Palate

Rapid palatal expanders (RPEs) are commonly used in patients with cleft lip and palate (CLP) prior to secondary alveolar bone grafting (SABG). Their position and size can impede tongue movement and affect speech. This study assessed changes in perception and production of speech over the course of RPE treatment.

Prospective longitudinal.

Tertiary university-affiliated hospital.

Twenty-five patients with unilateral CLP treated with Fan-type RPEs, and their parents.

Patient and parent speech questionnaires and patient speech recordings were collected at baseline before RPE insertion (T1), directly after RPE insertion (T2), during RPE expansion (T3), during RPE retention (T4), directly after RPE removal but before SABG (T5), and at short-term follow-up after RPE removal and SABG (T6).

Ratings for patient and parent questionnaires, first (F1) and second (F2) formants for vowels /a/, /i/, and /u/, and nasalance scores for non-nasal and nasal sentences, were obtained and analyzed using mixed model analyses of variance.

Ratings worsened at T2. For the vowel /a/, F1 and F2 were unchanged at T2. For the vowel /i/, F1 increased and F2 decreased at T2. For the vowel /u/, F1 was unchanged and F2 decreased at T2. Nasalance was unchanged at T2. All outcome measures returned to T1 levels by T4.

RPE insertion resulted in initial adverse effects on speech perception and production, which decreased to baseline prior to removal. Information regarding transient speech dysfunction and distress may help prepare patients for treatment.

On the Benefits of Speech-Language Therapy for Individuals Born With Cleft Palate: A Systematic Review and Meta-Analysis of Individual Participant Data

PURPOSE

Cleft lip and/or palate (CLP) is a common birth defect, and after reconstructive surgery, about 50% of children at 5 years of age have speech deviations and are referred to speech-language therapy (SLT). The peer-reviewed evidence for the benefit of SLT has been uncertain. Our objective was to systematically review and meta-analytically summarize the benefit of SLT for individuals born with CLP.

METHOD

A systematic search was conducted (last search on February 19, 2021) on studies evaluating SLT with pre and post measures on speech production, language ability, intelligibility, and/or patient-reported outcomes. We sought individual participant data (IPD) and evaluated on an individual level if the outcome measure had improved to a clinically relevant degree during SLT and if the outcome measure was on a level with peers or not after SLT. Meta-analyses and meta-regressions were applied to synthesize IPD across studies.

RESULTS

Thirty-four eligible studies were found. Nineteen studies provided IPD (n = 343) for the main analysis on speech production. The synthesized information suggests that, during SLT, speech production improved to a clinically relevant degree for many individuals (95% CI [61%, 87%]) and that speech production was on a level with peers for some individuals after SLT (95% CI [10%, 34%]).

CONCLUSIONS

The main strength of this meta-analysis is that we evaluated on an individual level pre- and post-intervention data based on considerations of clinical relevance. This approach allowed us to conclude that many individuals benefit from SLT and that further work on evaluating SLT in this patient group is meaningful. Supplemental Material https://doi.org/10.23641/asha.17700992.

Quality of Life of Adopted Chinese Versus Nonadopted Dutch Children with Cleft Lip and/or Palate: A Propensity Score Matched Analysis

Objective

To examine quality of life in internationally adopted children with cleft lip and/or palate (CL/P) versus non-adopted children with CL/P.

Design

Cross sectional study.

Setting

Multidisciplinary cleft team of a secondary and tertiary hospital in the Netherlands.

Methods

Parents of children under the age of 8 treated by the multidisciplinary cleft team of our institutions were asked to fill out a questionnaire containing demographic and clinical data and a validated parent proxy measure of cleft-specific quality of life instrument for children aged 0–8: the CleftChild-8. Adopted children were matched to non-adopted children using propensity score matching based on sex, age, type of cleft, if palatal surgery was completed and the level of education of the parent. CleftChild-8 scores were then compared between the matched samples of adopted and non-adopted children with CL/P.

Main Outcome Measure(s)

Differences in (sub)domain scores of the CleftChild-8.

Results

Most median CleftChild-8 scores of the adopted children (n = 29) were slightly lower compared to the 29 matched non-adopted children. A significant difference was seen for the domain score ‘satisfaction with (operative) treatment’ and 3 of the 13 subdomain scores: ‘post-operative results’, ‘acceptance by siblings’ and ‘acceptance by family/friends’.

Conclusions

By parent report, adopted children with CL/P experienced some areas of lower quality of life when compared to non-adopted children. Members of cleft teams should be aware of the problems associated with adoption and offer additional guidance and counseling to adopted children and their parents.

Farsi version of the CLEFT-Q: translation, cultural adaptation process and reliability

Background

The purpose of this study was the translation and cultural adaptation of the CLEFT-Q to Farsi and evaluating the reliability of it.

Methods

The English version of the CLEFT-Q was translated to Farsi following the guidelines set forth by the International Society for Pharmacoeconomics and Outcomes Research (ISPOR). To calculate the reliability, 50 participants filled out the Farsi version of the questionnaire twice at 2-week intervals.

Results

The difficulties during the translation and cultural adaptation process were as follows: 7.56% of items from the independent forward translations, 62.18% of items from the comparison between two forward translations, and 21% of items from the comparison between post-back translation and the original version. The internal consistency and stability of the Farsi version of the CLEFT-Q were 0.979 and 0.997, which both were categorized as excellent.

Conclusion

The Farsi version of the CLEFT-Q is a valid and reliable tool currently available for Farsi-speaking families around the world.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12903-021-01957-7.

The Impact of Maxillary Osteotomy on Fricatives in Cleft Lip and Palate: A Perceptual Speech and Acoustic Study

INTRODUCTION

Abnormal facial growth is a recognized outcome in cleft lip and palate (CLP), resulting in a concave profile and a class III occlusal status. Maxillary osteotomy (MO) is undertaken to correct this facial deformity, and the surgery can impact speech articulation, although the evidence remains limited and ill-defined for the CLP population.

AIMS

The aim of the study was to investigate the impact of MO on the production of the fricatives /f/ and /s/, using perceptual and acoustic analyses, and to explore the nature of speech changes.

METHODS

Twenty participants with CLP were seen 0-3 months pre-operatively (T1) and 3 months (T2) and 12 months (T3) after MO. A normal group (N = 20) was similarly recruited. Perceptual speech data was collected according to a validated framework and ratings made on audio and audio-video recordings (VIDRat). Spectral moments were centre of gravity (CG), standard deviation (SD), skewness (SK) and kurtosis (KU). Reliability studies were carried out for all speech analyses.

RESULTS

For the CLP group, VIDRat identified dentalization/interdentalization as the main type of pre-operative error for /s/ with a statistically significant improvement over time, χ2(2) = 6.889, p = 0.032. Effect sizes were medium between T1 and T3 (d = 0.631) and small between T2 and T3 (d = 0.194). For the acoustic data, effect sizes were similarly medium between T1 and T2 (e.g., SK, /f/ d = 0.579, /s/ d = 0.642) and small between T1 and T3 across all acoustic parameters. Independent t tests showed mainly statistically significant differences between both groups at all time points with large effect sizes (e.g., T2 CG, t = -4.571, p < 0.001, d =1.581), indicating that /s/ was not normalized post-operatively. For /f/, differences tended to be at T1 with large effect sizes (e.g., CG, t = -2.307, p = 0.028, d = 0.797), reflecting normalization.

CONCLUSIONS AND IMPLICATIONS

This is the first speech acoustic study on /f/ for individuals with CLP undergoing MO. The surgery has a positive impact on /f/ and /s/, which appear to stabilize 3 months post-operatively. Speech changes are an automatic and a direct consequence of the physical changes brought about by MO, effecting articulatory re-organization. The results of the study have direct clinical implications for the clinical care pathway for patients with CLP undergoing MO.

Deeper Understanding of Appearance in Orofacial Clefts: A Structural Equation Model of the CLEFT-Q Appearance Scales

Background

The CLEFT-Q is a patient-reported outcome measure with seven scales measuring elements of facial appearance in cleft lip and/or palate. We built on the validated CLEFT-Q structural model to describe conceptual relationships between these scales, and tested our hypothesis through structural equation modeling (SEM). In our hypothesized model, the appearance of the nose, nostrils, teeth, jaw, lips, and cleft lip scar all contribute to overall facial appearance.

Methods

We included 640 participants from the international CLEFT-Q field test. Model fit was assessed using weighted least squares mean and variance adjusted regression. The model was then refined through modification indices. The fit of the hypothesized model was confirmed in an independent sample of 452 participants.

Results

The refined model demonstrated excellent fit to the data (comparative fit index 0.999, Tucker-Lewis index 0.999, root mean square error of approximation 0.036 and standardized root mean square residual 0.036). The confirmatory analysis also demonstrated excellent model fit.

Conclusion

Our structural model, based on a clinical understanding of appearance in orofacial clefting, aligns with CLEFT-Q field test data. This supports the instrument's use and the exploration of a wider range of applications, such as multidimensional computerized adaptive testing.

An international study to develop the EAR-Q patient-reported outcome measure for children and young adults with ear conditions

BACKGROUND

There is currently a lack of patient-reported outcome measures for ear reconstruction. We developed the EAR-Q to measure ear appearance and post-operative adverse effects from the patient perspective.

METHODS

Field-test data were collected from children and young adults in eight countries between 13 May 2016 and 12 December 2019. Rasch measurement theory (RMT) analysis was used to refine the scales and to examine their psychometric properties.

RESULTS

Participants had microtia (n = 607), prominent ears (n = 145) or another ear condition (n = 111), and provided 960 assessments for the Appearance scale (e.g., size, shape, photos), and 137 assessments for the Adverse Effects scale (e.g., itchy, painful, numb). RMT analysis led to the reduction of each scale to 10-items. Data fit the Rasch model for the Appearance (X2(80) = 90.9, p = 0.19) and Adverse Effects (X2(20) = 24.5, p = 0.22) scales. All items in each scale had ordered thresholds and good item fit. There was no evidence of differential item function for the Appearance scale by age, gender, language, or type of ear condition. Reliability was high for the Appearance scale, with person separation index (PSI) and Cronbach alpha values with and without extremes ≥0.92. Reliability for the Adverse Effects scale was adequate (i.e., PSI and Cronbach alpha values ≥0.71). Higher scores (liked appearance more) correlated with higher scores (better) on Psychological, Social and School scales.

INTERPRETATION

The EAR-Q can be used in those 8-29 years of age to understand the patient perspective in clinical practice and research, and in addition, can be used to benchmark outcomes for ear reconstruction internationally.

Recursive Partitioning vs Computerized Adaptive Testing to Reduce the Burden of Health Assessments in Cleft Lip and/or Palate: Comparative Simulation Study

BACKGROUND

Computerized adaptive testing (CAT) has been shown to deliver short, accurate, and personalized versions of the CLEFT-Q patient-reported outcome measure for children and young adults born with a cleft lip and/or palate. Decision trees may integrate clinician-reported data (eg, age, gender, cleft type, and planned treatments) to make these assessments even shorter and more accurate.

OBJECTIVE

We aimed to create decision tree models incorporating clinician-reported data into adaptive CLEFT-Q assessments and compare their accuracy to traditional CAT models.

METHODS

We used relevant clinician-reported data and patient-reported item responses from the CLEFT-Q field test to train and test decision tree models using recursive partitioning. We compared the prediction accuracy of decision trees to CAT assessments of similar length. Participant scores from the full-length questionnaire were used as ground truth. Accuracy was assessed through Pearson's correlation coefficient of predicted and ground truth scores, mean absolute error, root mean squared error, and a two-tailed Wilcoxon signed-rank test comparing squared error.

RESULTS

Decision trees demonstrated poorer accuracy than CAT comparators and generally made data splits based on item responses rather than clinician-reported data.

CONCLUSIONS

When predicting CLEFT-Q scores, individual item responses are generally more informative than clinician-reported data. Decision trees that make binary splits are at risk of underfitting polytomous patient-reported outcome measure data and demonstrated poorer performance than CATs in this study.

Speech Outcome and Self-Reported Communicative Ability in Young Adults Born With Unilateral Cleft Lip and Palate: Comparing Long-Term Results After 2 Different Surgical Methods for Palatal Repair

OBJECTIVE

To compare speech outcome and self-reported speech and communicative ability (SOK) in young adults treated with one-stage (OS) or two-stage (TS) palatal repair. Furthermore, to compare with normative data on individuals without cleft lip and palate and to study the relationship between patients' and experts' judgments.

DESIGN

A cross-sectional group comparison study with long-term follow-up. Participants: Patients born with unilateral cleft lip and palate treated at 2 cleft centers; 17 with OS at 14 months and 25 with TS, soft palate repair at 7 months and hard palate repair at 6.2 years. Pharyngeal flap surgery was performed in 53% (OS) and 24% (TS) of patients.

MAIN OUTCOME MEASURE(S)

Speech characteristics were blindly assessed by speech and language pathologist from audio recordings, SOK at 19 years of age.

RESULTS

No group differences were found. Although the occurrence of nasality symptoms was low in both groups, only 60% (OS)/65% (TS) were assessed with competent velopharyngeal function (VPC). Articulation proficiency (percentage of consonants correct [PCC]) was 91%/97%, the /s/-sound specifically 87%/91%. Good intelligibility was found in 91%/87%. Patient opinion was in agreement with norms and significantly associated with intelligibility (rs = 0.436, P < .01), PCC (rs = -0.534, P < .01), and correct /s/ (rs = -0.354, P < .05).

CONCLUSIONS

No differences in speech outcome were related to operation method. The low prevalence of VPC was not clearly reflected in nasality symptoms. Patient opinion was related to articulation and intelligibility. A higher burden of care in terms of pharyngeal flap surgery was seen after the OS technique.

Evaluation of Quality of Life in Adult Individuals With Cleft Lip and/or Palate

OBJECTIVES

The purpose of the present study was to systematically review literature relating to the quality of life (QoL) in adult individuals with cleft lip and/or palate (CLP) and identify which aspect of QoL adults with CLP find to be the most problematic, in comparison to a general non-cleft population.

DESIGN

Different databases were searched for this review including the Cochrane Central Register of Controlled Trials, Ovid MEDLINE and Embase. Five domains of QoL were identified to evaluate the overall results of these QoL measures. These domains were; physical function, physical pain, psychological implications and self-esteem, self-perception in relation to facial aesthetics, and social function. The studies included underwent critical appraisal and different types of bias were assessed based on the Cochrane handbook for systematic reviews of interventions.

RESULTS

Ten studies were included in this review. The total number of participants was 541. The most common QoL measure for adults with CLP was Short-Form (SF-36). Seven studies out of 10 reported statistically significantly worse scores (P < 0.05) in the psychological implications and self-esteem domains of QoL in adults with CLP, indicating lower QoL in terms of these domains. The least affected QoL domain was physical function. A high heterogeneity was found among the studies, including variation in the QoL measures, types of orofacial clefts, types of treatment and comparison groups.

CONCLUSION

The presence of CLP did seem to negatively affect the QoL for adults with CLP, mainly in terms of psychological implications and self-esteem.

FACE-Q Craniofacial Module: Part 1 validation of CLEFT-Q scales for use in children and young adults with facial conditions

BACKGROUND

The CLEFT-Q includes 12 independently functioning scales that measure appearance (face, nose, nostrils, teeth, lips, jaws), health-related quality of life (psychological, social, school, speech distress), and speech function, and an eating/drinking checklist. Previous qualitative research revealed that the CLEFT-Q has content validity in noncleft craniofacial conditions. This study aimed to examine the psychometric performance of the CLEFT-Q in an international sample of patients with a broad range of facial conditions.

METHODS

Data were collected between October 2016 and December 2019 from 2132 patients aged 8 to 29 years with noncleft facial conditions. Rasch measurement theory (RMT) analysis was used to examine Differential Item Function (DIF) by comparing the original CLEFT-Q sample and the new FACE-Q craniofacial sample. Reliability and validity of the scales in a combined cleft and craniofacial sample (n=4743) were examined.

RESULTS

DIF was found for 23 CLEFT-Q items when the datasets for the two samples were compared. When items with DIF were split by sample, correlations between the original and split person locations showed that DIF had negligible impact on scale scoring (correlations ≥0.995). In the combined sample, RMT analysis led to the retention of original content for ten CLEFT-Q scales, modification of the Teeth scale, and the addition of an Eating/Drinking scale. Data obtained fit with the Rasch model for 11 scales (exception School, p=0.04). Person Separation Index and Cronbach alpha values met the criteria.

CONCLUSION

The scales described in this study can be used to measure outcomes in children and young adults with cleft and noncleft craniofacial conditions.

Comparison of Corresponding Scores From the Cleft Hearing Appearance and Speech Questionnaire (CHASQ) and CLEFT-Q in Swedish Patients With Cleft Lip and/or Palate

OBJECTIVE

The primary aim of this study was to compare corresponding scores between 2 existing cleft-specific patient-reported outcome measures (PROMs)-Cleft Hearing Appearance and Speech Questionnaire (CHASQ) and CLEFT-Q. The second aim of the study was to investigate patient opinion on the 2 PROMs.

DESIGN

Cross-sectional questionnaire study.

SETTING

Participants were recruited from a University Hospital. They answered CHASQ and CLEFT-Q either in the hospital or at home.

PARTICIPANTS

Thirty-three participants with cleft lip and/or palate, aged 10 to 19 years.

MAIN OUTCOME MEASURE

CHASQ and CLEFT-Q.

RESULTS

The CHASQ scores and the corresponding CLEFT-Q scores on appearance correlated significantly. Corresponding scores regarding speech did not correlate significantly. A majority, 15 (58%) participants, answered that they liked CLEFT-Q more than CHASQ, 18 participants (69%) thought CHASQ was easier to complete, and 19 (76%) thought CLEFT-Q would better inform health care professionals.

CONCLUSION

Both instruments showed strengths and limitations. Clinicians will have to consider each instrument's respective qualities when choosing to implement either PROM.

FACE-Q craniofacial module: Part 2 Psychometric properties of newly developed scales for children and young adults with facial conditions

BACKGROUND

The FACE-Q Craniofacial Module is a patient-reported outcome measure designed for patients aged 8 to 29 years with conditions associated with a facial difference. In part 1, we describe the psychometric findings for the original CLEFT-Q scales tested in patients with cleft and noncleft facial conditions. The aim of this study was to examine psychometric performance of new FACE-Q Craniofacial Module scales.

METHODS

Data were collected between December 2016 and December 2019 from patients aged 8 to 29 years with conditions associated with a visible or functional facial difference. Rasch measurement theory (RMT) analysis was used to examine psychometric properties of each scale. Scores were transformed from 0 (worst) to 100 (best) for tests of construct validity.

RESULTS

1495 participants were recruited with a broad range of conditions (e.g., birthmarks, facial paralysis, craniosynostosis, craniofacial microsomia, etc.) RMT analysis resulted in the refinement of 7 appearance scales (Birthmark, Cheeks, Chin, Eyes, Forehead, Head Shape, Smile), two function scales (Breathing, Facial), and an Appearance Distress scale. Person separation index and Cronbach alpha values met criteria. Three checklists were also formed (Eye Function, and Eye and Face Adverse Effects). Significantly lower scores on eight of nine scales were reported by participants whose appearance or functional difference was rated as a major rather than minor or no difference. Higher appearance distress correlated with lower appearance scale scores.

CONCLUSION

The FACE-Q Craniofacial Module scales can be used to collect and compare patient reported outcomes data in children and young adults with a facial condition.

Patient satisfaction and quality of life after orthodontic treatment for cleft lip and palate deformity

OBJECTIVES

Patients with cleft lip-cleft palate (CLP) often require orthodontic treatment, with or without orthognathic surgery. Patient satisfaction is the most important outcome parameter in orthodontic treatment. This study aimed to (1) determine patient satisfaction and quality of life (QoL) after orthodontic treatment and (2) identify associated factors.

MATERIAL AND METHODS

This prospective cross-sectional study recruited patients with CLP who had completed orthodontic treatment at a craniofacial center in Taiwan. Participants (N=213) had received treatment for unilateral CLP (n=99), bilateral CLP (n=50), cleft lip and alveolus (n=39), and isolated cleft palate (n=25). Self-report questionnaires evaluated satisfaction with appearance and QoL; multiple regression analysis examined associated factors. Participants' expectations of treatment results were also reported.

RESULTS

Participants reported moderate satisfaction with facial appearance and QoL. Satisfaction with treatment was lower or much lower than expected for 13% of participants. Treatment for bilateral CLP was associated with the lowest satisfaction with overall appearance (r = -8.123, P < 0.05); participants who had received orthognathic surgery had the highest satisfaction (r = 5.534, P < 0.05). Treatment for unilateral and bilateral CLP was associated with low QoL for smile (both P < 0.05).

CONCLUSIONS

Orthodontic treatment had a positive effect on facial appearance and quality of life in patients with CLP. Type of cleft and orthognathic surgery significantly influenced satisfaction with facial appearance.

CLINICAL RELEVANCE

Efforts must be taken to modify treatment strategies for patients with bilateral CLP in order to improve satisfaction with appearance following treatment.

Rasch Analysis of Patient- and Parent-Reported Outcome Measures in the International Consortium for Health Outcomes Measurement Standard Set for Cleft Lip and Palate

OBJECTIVES

The aim of this study was to evaluate the psychometric performance of the patient- and parent-reported measures in the International Consortium for Health Outcomes Measurement (ICHOM) Standard Set for Cleft Care, and to identify ways of improving concept coverage.

METHODS

Data from 714 patients with cleft lip and/or palate, aged 8 to 9, 10 to 12.5, and 22 years were collected between November 2015 and April 2019 at Erasmus University Medical Center, Boston Children's Hospital, Duke Children's Hospital, and from participating sites in the CLEFT-Q Phase 3 study. The Standard Set includes 9 CLEFT-Q scales, the Nasal Obstruction Symptom Evaluation (NOSE) questionnaire, the Child Oral Health Impact Profile-Oral Symptoms Scale (COHIP-OSS), and the Intelligibility in Context Scale (ICS). Targeting, item-fit statistics, thresholds for item responses, and measurement precision (PSI) were analyzed using Rasch measurement theory.

RESULTS

The proportion of the sample to score within each instruments range of measurement varied from 69% (ICS) to 92% (CLEFT-Q teeth and COHIP-OSS). Specific problems with individual items within the NOSE and COHIP-OSS questionnaires were noted, such as poor item fit to the Rasch model and disordered thresholds (6 of 10). Reliability measured with PSI was above 0.82 for the ICS and all but one CLEFT-Q scale (speech distress). PSIs were lowest for the COHIP-OSS (0.43) and NOSE questionnaire (0.35).

CONCLUSION

The patient- and parent-reported components within the facial appearance, psychosocial function, and speech domains are valid measures; however, the facial function and oral health domains are not sufficiently covered by the CLEFT-Q eating and drinking, NOSE, and COHIP-OSS, and these questionnaires may not be accurate enough to stratify cleft-related outcomes.

Establishing content validity of an orthodontic subset of the FACE-Q Craniofacial Module in children and young adults with malocclusion

OBJECTIVE

The FACE-Q Craniofacial Module for children and young adults is a patient-reported outcome measure (PROM) designed to measure outcomes for patients aged 8 to 29 years with facial conditions. The aim of this study was to establish content validity of a relevant subset of the module for its use in orthodontic patients with malocclusion.

SETTING AND SAMPLE POPULATION

Experts in orthodontics were emailed and invited to provide feedback through a Research Electronic Data Capture survey. Patient feedback was obtained through cognitive interviews with patients aged 8 to 29 years recruited from a university-based orthodontic clinic in Canada.

MATERIALS AND METHODS

Expert opinion and patient interviews were used to obtain feedback on the content of 4 appearance (face, smile, teeth and jaws) and 1 function (eating and drinking) scales hypothesized to be relevant to orthodontic malocclusions, and to elicit new concepts. Interviews were audio-recorded, transcribed, and coded using a line-by-line approach.

RESULTS

Twenty-one experts and 15 patients participated. Expert feedback led us to drop 9, retain 40, revise 4 and add 16 new items. At the conclusion of cognitive interviews no items were dropped, 55 were retained, 5 were revised and 8 new items were added. The final set of 68 items demonstrated content validity for orthodontic patients.

CONCLUSION

Expert feedback and cognitive interviews enabled us to revise and refine 5 scales as part of the FACE-Q Craniofacial Module for use in orthodontic patients. These scales were included in the internationalfield-test of the FACE-Q Craniofacial Module.

Atypical Outcomes of Nasal and Lip Appearance After Unilateral Cleft Lip Repair: Judgment by Professionals, Patients, and Laypeople

Objective:

To gain more insight into the assessment of “atypical” nasal and lip appearance outcomes compared to “typical” appearance outcomes after unilateral cleft lip and palate (UCLP) repair, when judged by professionals, patients with repaired UCLP, and laypeople.

Design:

An online survey containing 3 series of photographs with various degrees of “typical” and “atypical” nasal and lip appearance outcomes after UCLP repair was sent to 30 professionals, 30 patients with repaired UCLP, and 50 laypeople in 2 countries. Participants were instructed to rank the photographs from excellent to poor based on overall appearance. Mean rank positions of photographs were analyzed and differences in mean rank score between “typical” and “atypical” results were assessed using a T-test. Agreement of ranking between the 3 groups was assessed with an analysis of variance analysis.

Setting:

Amsterdam UMC, location VUmc, Netherlands and Boston Children’s Hospital, Boston, USA.

Patients:

Photographs of 6- to 18-year-old patients with repaired UCLP.

Results:

“Atypical” appearance outcomes were ranked significantly less favorably (small nostril: P = 0.00; low vermillion border: P = 0.02; whistling deformity: P = 0.00) compared to “typical” outcomes. Difference between professionals, patients and laypeople in rank positioning the photographs was not statistically significant (P = 0.89).

Conclusions:

Noses with a smaller nostril and lips containing a whistling deformity were perceived as poorer outcome compared to the “typical” results. Professionals, patients, and laypeople are in agreement when assessing these outcomes.

Optimising the computerised adaptive test to reliably reduce the burden of administering the CLEFT-Q: A Monte Carlo simulation study

BACKGROUND

Computerised adaptive testing (CAT) has the potential to transform plastic surgery outcome measurement by making patient-reported outcome measures (PROMs) shorter, individualised and more accurate than pen-and-paper questionnaires.

OBJECTIVES

This paper reports the results of two optimisation studies for the CLEFT-Q CAT, a CAT intended for use in the field of cleft lip and/or palate. Specifically, we aimed to identify the optimal score estimation and item selection methods for using this CAT in clinical practice. These represent two major components of any CAT algorithm.

METHOD

Monte Carlo simulations were performed using simulated data in the R statistical computing environment and incorporated a range of score estimation and item selection techniques. The performance and accuracy of the CAT was assessed by mean items administered, correlation between CAT scores and paired linear assessment scores, and the root mean squared deviation (RMSD) of these score pairs.

RESULTS

The accuracy of the CLEFT-Q CAT was not significantly affected by the choice of score estimation or item selection method. Sub-scales which originally contain more items were amenable to greater item reduction with CAT.

CONCLUSION

This study shows that score estimation and item selection methods that need minimal processing power can be used in the CLEFT-Q CAT without compromising accuracy. This means that the CLEFT-Q CAT could be administered quickly and efficiently with basic hardware demands. We recommend the use of less computationally intensive techniques in future CLEFT-Q CAT studies.

Experiences of Canadian Parents of Young Children With Cleft Lip and/or Palate

PURPOSE

Prior literature has described the perspectives of parents of young children with clip lip and/or palate; however, few studies have described parents' experiences within a Canadian health care system. This study aims to better understand the experiences of parents of young children with cleft lip and/or palate seen at a Canadian tertiary care center and identify their care needs.

DESIGN

In-depth semistructured interviews.

SETTING

Pediatric tertiary care center.

PARTICIPANTS

Parents of children younger than 7 years of age with cleft lip and/or palate.

RESULTS

From 14 interviews, 4 themes were identified. The diagnosis theme was associated with reactions, timing, and search for information. Key concerns within the theme of physiology and function were around feeding and speech. The health care experience theme included burden of care, peripheral hospitals and services, the cleft lip and palate clinic, and clinicians. The psychosocial theme included parents' reactions to their child's pain, coping strategies, family interactions, and school/day care experiences. Parents felt care could be improved by having: access to good information and community speech therapists, shorter appointment wait times, a peer support network, and increased cleft knowledge within their child's school and peer groups.

CONCLUSIONS

The experience of parents of children with cleft lip and/or palate is complex but can be organized into 4 themes. Clinics may consider suggestions offered by parents to improve care. Future work should address parents' needs and aim to create a parent-reported quality-of-life measure specific to parents of young children with cleft lip and/or palate.