Speech in Children with an Isolated Cleft Palate: A Longitudinal Perspective

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

To investigate the relationship between patient-related factors (sex, cleft type, cleft extent, and Robin Sequence [RS]) and speech outcome at 5 years of age for children born with a cleft palate ±  lip (CP ± L).

3157 Children (1426 female:1731 male) with a nonsyndromic CP ± L, born between 2006 and 2014 in England, Wales, and Northern Ireland.

Perceptual speech analysis utilized the Cleft Audit Protocol for Speech-Augmented (CAPS-A) rating and UK National Speech Outcome Standards: Speech Standard 1 (SS1)-speech within the normal range, SS2a-no structurally related speech difficulties or history of speech surgery, and SS3-speech without significant cleft-related articulation difficulties.

Odds of achieving SS1 were lower among boys (aOR 0.771 [CI 0.660-0.901]), those with clefts involving the lip and palate (vs palate only) (UCLP-aOR 0.719 [CI 0.591-0.875]; BCLP-aOR 0.360 [CI 0.279-0.463]), and clefts involving the hard palate (incomplete-aOR 0.701 [CI 0.540-0.909]; complete-aOR 0.393 [CI 0.308-0.501]). Similar relationships with these patient factors were observed for SS3. SS2 was affected by the extent of hard palate involvement (complete; aOR 0.449 [CI 0.348-0.580]). Although those with CP and RS were less likely to meet all 3 standards than those without RS, odds ratios were not significant when adjusting for sex and cleft extent.

Sex, cleft type, and extent of hard palate involvement have a significant impact on speech outcome at 5 years of age. Incorporating these factors into risk-adjustment models for service-level outcome reporting is recommended.

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

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

Compensatory Articulation Errors in Patients With Velopharyngeal Dysfunction and Palatal Anomalies

PURPOSE

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

METHOD

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

RESULTS

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

CONCLUSIONS

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

Consequences of rare diagnoses for education and daily life: development of an observation instrument

Background

Ågrenska, a Swedish national centre for rare diagnoses and health conditions, has arranged courses for families of children with rare diagnoses for over thirty years, and has experienced that the conditions often have complex and varying consequences in the children´s everyday lives, not least in educational contexts. Knowledge of these consequences and of how to adapt the environment and educational methods is often lacking and the children´s educational needs are not met. Many professionals also report a lack of sources of knowledge. Knowledge formation and dissemination about educational consequences of rare diagnoses are thus of utmost importance. For this purpose, a broad observation instrument was constructed in order to gather knowledge on a group level concerning how functional impairments affect school and everyday situations, how consequences vary within each diagnosis and if there are diagnosis-specific features that lead to specific every day and pedagogical consequences.

Results

The instrument consists of 119 quantitative and 65 qualitative items and covers ten domains: social and communicative ability, emotions and behaviours, communication and language, ability to manage his/her disability and everyday life, activities of daily life, gross and fine motor skills, perception and worldview, prerequisites for learning and basic school abilities. The instrument is intended for use by educational professionals with knowledge of typical development and was content validated against existing instruments. The items were considered relevant as they, with few exceptions, appear in well-known assessment tools. Interrater reliability was based on the observations of six children. Each child was observed by two educators. Interrater reliability was calculated for the quantitative items and items with fixed response options, including yes/no answers, a total of 100 items, which are usually observed during the course. Interrater reliability reached 91%. Factor analysis and Cronbach´s alpha indicated good statistical properties and a multinomial regression gave reasonable results.

Conclusions

The instrument can be used to gather knowledge on a group level of educational and everyday consequences of rare diagnoses. This knowledge can be used to adapt methods and environment to meet the educational needs and create conditions for optimal learning and participation for children with rare health conditions.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13023-022-02303-y.

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

PURPOSE

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

METHOD

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

RESULTS

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

CONCLUSIONS

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

The impact of hearing loss on speech outcomes in 5-year-old children with cleft palate ± lip: A longitudinal cohort study

OBJECTIVES

To investigate the impact of hearing loss (using longitudinal measurements of hearing) on speech outcomes at age 5 (5 years 0 months-5 years 11 months) in children born with cleft palate ± lip. Other variables which may impact upon the speech outcomes at age 5 in this population were also investigated.

METHODS

A retrospective longitudinal cohort study of children, without a named syndrome, born with cleft palate ± lip, and treated at a Cleft Centre in the United Kingdom. Data collected from infancy to 5 years 11 months, included hearing test results from three specific time points (7 months-1 year 2 months [age A]; 2 years 0 months-2 years 11 months [age B]; 5 years 0 months-5 years 11 months [age C]) and speech outcome data at age 5 years (5 years 0 months-5 years 11 months). Hearing test results at each age were compared to identify how hearing changes with age. Correlations between hearing test results and speech outcomes at age 5 were analysed.

RESULTS

Hearing loss was frequent but predominantly mild. There were no significant correlations between speech outcomes and hearing results at any age. Mild hearing loss remained prevalent at age 5, although a significant age-related hearing improvement was found. A significant relationship between cleft type and cleft speech characteristics was found (P < .001); children with Bilateral Cleft Lip and Palate achieved the poorest articulation outcomes.

CONCLUSION

Although mild hearing loss was common in the cohort, there was no association between hearing loss and the speech outcomes investigated. In contrast, the type of cleft was significantly associated with the presence of cleft speech characteristics. Further longitudinal measurement of hearing is required to substantiate the findings of this study.

Greater Palatal Cleft Width Predicts an Increased Risk for Unfavorable Outcomes in Cleft Palate Repair

OBJECTIVE

To investigate the impact of cleft width and cleft type on the need for secondary surgery and velopharyngeal competence from a longitudinal perspective.

DESIGN

Retrospective, longitudinal study.

SETTING

A single multidisciplinary craniofacial team at a university hospital.

PATIENTS

Consecutive patients with unilateral or bilateral cleft lip and palate and cleft palate only (n = 313) born from 1984 to 2002, treated with 2-stage palatal surgery, were reviewed. A total of 213 patients were included.

MAIN OUTCOME MEASURES

The impact of initial cleft width and cleft type on secondary surgery. Assessment of hypernasality, audible nasal emission, and glottal articulation from routine follow-ups from 3 to 16 years of age. The assessments were compared with reassessments of 10% of the recordings.

RESULTS

Cleft width, but not cleft type, predicted the need for secondary surgery, either due to palatal dehiscence or velopharyngeal insufficiency. The distribution of cleft width between the scale steps on a 4-point scale for hypernasality and audible nasal emission differed significantly at 5 years of age but not at any other age. Presence of glottal articulation differed significantly at 3 and 5 years of age. No differences between cleft types were seen at any age for any speech variable.

CONCLUSIONS

Cleft width emerged as a predictor of the need for secondary surgery as well as more deviance in speech variables related to velopharyngeal competence during the preschool years. Cleft type was not related to the need for secondary surgery nor speech outcome at any age.

Speech input processing in children born with cleft palate: A systematic literature review with narrative synthesis

BACKGROUND

Speech development requires intact and adequately functioning oral anatomy and cognitive 'speech processing' skills. There is evidence that speech input processing skills are associated with speech output problems in children not born with a cleft. Children born with cleft palate ± lip (CP±L) are at high risk of developing disordered speech output. Less is known about their speech input processing skills and whether they are associated with cleft-related speech sound disorder (SSD).

AIMS

(1) To collate and evaluate studies reporting evidence regarding the speech input processing skills of children born with cleft palate in comparison with data from typically developing children or other comparison groups; and (2) to identify any available evidence regarding relationships between speech input processing skills and speech output in children born with CP±L.

METHODS & PROCEDURES

Potentially relevant studies published up to November 2019 were identified from the following databases: Medline via Ovid, Embase via Ovid, Cinahl via Ebscohost, PsycInfo via Ebscohost, BNI via ProQuest, AMED via Ovid, Cochrane Library and Scopus. Inclusion criteria were: peer-reviewed articles published in scientific journals, any design, published in English, participants born with a CP±L aged up to age 18 years who completed speech input processing assessments compared with normative data and/or a control or other comparison group. Critical Appraisal Skills Programme (CASP) checklists were used to quality appraise included studies.

OUTCOMES & RESULTS

Six studies were retained in the final review. There is some evidence that children born with CP±L perform less well than non-cleft controls on some speech input processing tasks and that specific input processing skills may be related to errors in the children's speech. Heterogeneity in relation to study groups and assessments used, as well as small sample sizes, limits generalization of findings.

CONCLUSION & IMPLICATIONS

There is limited evidence regarding the speech input processing skills of children born with CP±L. There are indications that children born with CP+/L may have difficulty in some aspects of speech input processing in comparison with children not born with a cleft, and that difficulties with some speech input processing tasks may be specific to errors in children's speech output. Further research is required to develop our understanding of these skills in this population and any associations with speech output.

WHAT THIS PAPER ADDS

What is already known on the subject Few studies have been published that examine aspects of speech input processing in children born with CP±L. Theoretical models of speech processing, and published studies, propose that speech input processing skills are associated with SSD in children who were not born with a cleft. However, it is less clear whether there is any association between speech input processing and cleft-related SSD. What this paper adds to existing knowledge This review systematically collates and evaluates the published, peer-reviewed evidence regarding speech input processing skills in children born with CP±L. The collated evidence indicates that some speech input processing skills differ between children with and without CP±L. There is some evidence, from a single study, that speech input processing of specific cleft speech characteristics (CSCs) may be associated with the presence of these CSCs in the speech output of some children born with CP±L. What are the potential or actual clinical implications of this work? While the evidence is currently limited, increasing our knowledge of speech input processing skills in children born with CP±L contributes to our clinical understanding of the nature of cleft-related SSD. The current evidence suggests that speech and language therapists should consider speech input processing skills when assessing children with cleft-related SSD to support intervention planning. Considering these skills in relation to literacy development in these children may also be important.

Non-Oral Compensatory Misarticulations Revisited

Non-oral compensatory misarticulation patterns are often associated with the speech of children with cleft palate. Despite their saliency, the etiology, frequency, and treatment of these misarticulations have not been studied extensively. The purpose of this commentary is to review what we know about these atypical patterns of articulation and address clinical assumptions regarding their etiology and treatment.

Palatal Re-Repair With Z-Plasty in Treatment of Velopharyngeal Insufficiency of Syndromic and Nonsyndromic Patients With Cleft Palate

BACKGROUND

Velopharyngeal insufficiency (VPI) often results from palatal shortening or insufficient levator function after cleft palate repair.

AIMS

To assess the efficacy of palatal re-repair with Z-plasty in treatment of VPI for patients with isolated cleft palate (ICP).

METHODS

This retrospective analysis comprised 130 consecutive patients who had ICP with VPI that required Z-plasty as secondary surgery between 2008 and 2017. Pre- and post-operative evaluation of velopharyngeal function was done perceptually and instrumentally by Nasometer.

RESULTS

Median patient age at Z-plasty was 6.8 years (range 3.0-20.1). Of the 130 patients, preoperatively VPI was severe in 73 (56%), mild-to-moderate in 55 (42%), and borderline in 2 (2%). Postoperatively, 105 (81%) of patients achieved adequate (normal or borderline) velopharyngeal competence and 16 (12%) required second operation for residual VPI. The success rate was 84% in nonsyndromic patients, 79% in nonsyndromic Pierre Robin sequence patients, and 58% in syndromic patients. In syndromic children, the speech outcome was significantly worse than in nonsyndromic children (P = 0.014). Complications included wound healing problems in 3 patients (2%), mild infection in 1 patient (1%), postoperative bleeding in 1 (1%), and postoperative fistula in 2 (2%).

CONCLUSION

Palatal re-repair with Z-plasty is a safe operation for VPI correction in patients with ICP with a success rate of 81%. In syndromic patients, the procedure did not seem to work as well as in nonsyndromic patients.

Benchmarking Speech, Velopharyngeal Function Outcomes and Surgical Characteristics Following the Sommerlad Protocol and Palate Repair Technique

Objective:

To report speech and velopharyngeal function (VPF) outcomes, and surgical characteristics, at age 5 following early complete palate closure using the Sommerlad protocol.

Design:

A retrospective, descriptive, cross-sectional consecutive series.

Setting:

A regional twin site center; a district general hospital and tertiary children’s hospital.

Participants:

Between 1993 and 2006, 877 participants underwent surgery; 712 (81%) were eligible for inclusion; 391 (55%) were included, 321 (45%) excluded. Thirteen percent had bilateral cleft lip and palate (CLP), 40% unilateral CLP, and 47% isolated cleft palate.

Intervention:

Lip and vomerine flap repair at 3 months of age (BCLP, UCLP) with soft palate closure using radical muscle dissection and retropositioning at a mean age of 6.6 months, range 4 to 23 months, as described and undertaken by Sommerlad.

Outcome Measures:

Velopharyngeal Composite (VPC) CAPS-A and articulation summary scores derived from analysis using the Cleft Audit Protocol for Speech-Augmented.

Results:

A VPC-SUM CAPS-A score of “0” was found in 97% reflecting adequate VPF; 73% had no cleft articulation difficulties. The BCLP group had the poorest articulation. Secondary speech surgery rate was 2.6% and 10.7% had fistula repair. Levator muscle quality and degree of retropositioning was associated with speech outcomes related to VPF. 2.6% had current features of VPI.

Conclusions:

Complete palate closure by around 6 months of age by the surgeon who described the technique led to excellent perceived VPF and very good speech outcomes at age 5, with less speech therapy and secondary speech surgery than commonly reported. These findings serve as a benchmark for the Sommerlad protocol and technique.

Assessing speech at three years of age in the cleft palate population: a scoping review of assessment practices

BACKGROUND

There is no consensus in the UK regarding the types of speech samples or parameters of speech that should be assessed at 3 years of age in children with cleft palate ± cleft lip (CP±L), despite cleft units routinely assessing speech at this age. The standardization of assessment practices would facilitate comparisons of outcomes across UK cleft units; earlier identification of speech impairments-which could support more timely treatments; and more reliable recording of therapy impacts and surgical interventions.

AIMS

To explore assessment practices used to assess speech in 3-year-old children with CP±L, including speech parameters, methods of assessment and the nature of the speech sample used.

METHODS & PROCEDURES

A broad examination of the literature was undertaken through the use of a scoping review conducted in accordance with Joanna Briggs Institute guidelines. Search terms were generated from a preliminary search and then used in the main search (Medline, CINAHL, Embase, AMED and PsycINFO).

MAIN CONTRIBUTION

A combination of approaches (medical, linguistic, developmental and functional) is required to assess CP±L speech at age 3. A developmental approach is recommended at this age, considering the complexity of speech profiles at age 3, in which typically developing speech processes may occur alongside cleft speech characteristics. A combined measure for both nasal emission and turbulence, and an overall measure for velopharyngeal function for speech, show potential for assessment at this age. Categorical ordinal scales are frequently used; the use of continuous scales has yet to be fully explored at age 3. Although single-word assessments, including a subset of words developed for cross-linguistic comparisons, are frequently used, more than one type of speech sample may be needed to assess speech at this age validly. The lack of consensus regarding speech samples highlights a need for further research into the types of speech samples 3-year-olds can complete; the impact of incomplete speech samples on outcome measures (particularly relevant at this age when children may be less able to complete a full sample); the impact of different speech samples on the validity of assessments; and the reliability of listener judgements.

CONCLUSIONS & IMPLICATIONS

Whilst a medical model and linguistic approaches are often central in assessments of age-3 cleft speech, this review highlights the importance of developmental and functional approaches to assessment. Cross-linguistic single-word assessments show potential, and would facilitate the comparison of UK speech outcomes with other countries. Further research should explore the impact of different speech samples and rating scales on assessment validity and listener reliability.

Speech Phenotyping in Unaffected Family Members of Individuals With Nonsyndromic Cleft Lip With or Without Palate

OBJECTIVE

Subclinical phenotypes of nonsyndromic cleft lip with or without cleft palate (CL ± P) may be identified from clinically "unaffected" relatives and could be associated with specific cleft-related gene mutations. It has been hypothesized that velopharyngeal insufficiency (VPI) may be a subclinical phenotype of interest in this population, but this has not been explored quantitatively with appropriate control cohorts. The aim of this case-control study was to compare VPI in at-risk clinically unaffected relatives of individuals with nonsyndromic CL ± P with a low-risk matched normative Australian cohort.

PARTICIPANTS

Clinically unaffected (ie, with no overt cleft) first-degree relatives of a proband with nonsyndromic CL ± P (n = 189) and noncleft controls (n = 207).

MAIN OUTCOME MEASURE(S)

Perceptual measures of VPI encompassing resonance, nasal emission, and articulation were evaluated using the Great Ormond Street Speech Assessment. Quantitative measures of VPI were obtained from the Nasometer II using standardized adult and pediatric speech stimuli.

RESULTS

Both perceptual and instrumental measures showed no significant difference (P > .01) between the VPI in unaffected relatives and the noncleft comparison group. Mean nasalance scores for both groups were calculated and reported according to speech stimuli, age, and sex.

CONCLUSIONS

Results suggest that VPI, measured through speech, is not a significant subclinical phenotype of nonsyndromic CL ± P. Therefore, further familial genetic investigations exploring VPI may not yield meaningful results. Exploration across multiple subclinical phenotypes in larger cohorts may enable researchers to better understand the multifaceted nature of this complex and heterogeneous anomaly.

Escala de Borg: um novo método para avaliação da hipernasalidade de fala

RESUMO Objetivo Investigar a confiabilidade da escala Borg centiMax como método de avaliação perceptivo-auditiva da hipernasalidade e a influência do tipo de amostra de fala sobre a confiabilidade das avaliações. Método Quatro fonoaudiólogas experientes classificaram a hipernasalidade de 80 amostras de fala de pacientes com fissura de palato reparada (40 vocábulos e 40 sentenças) utilizando a escala ordinal de 5 pontos e a escala Borg centiMax. Os índices de concordância intra e interavaliadores foram estabelecidos para ambas as escalas e amostras. A comparação desses índices foi feita pelo teste Z e a comparação entre as escalas foi feita pelo coeficiente de correlação de Spearman (p<0,05). Resultados Verificou-se correlação muito alta e significante entre a Escala Borg centiMax e a escala ordinal, para ambas as amostras. Os índices de concordância intra-avaliadores (CCI) para a escala Borg centiMax variaram de excelente a bom e, para a escala ordinal (Kappa), de excelente a pobre, em ambas as amostras. A concordância interavaliadores (CCI) para a escala Borg centiMax variou de excelente a moderada e, para a escala ordinal (Kappa), variou de moderada a pobre, para vocábulos e sentenças. Diferença estatisticamente significante, com melhores índices de concordância intra e interavaliadores para vocábulos, foi obtida com a escala Borg centiMax. Para a escala ordinal, diferença significante entre vocábulos e sentenças foi observada apenas para a comparação interavaliador. Conclusão A escala Borg centiMax apresentou melhores índices de concordância intra e interavaliadores. A amostra contendo vocábulos mostrou melhores índices de concordância na maioria das comparações, para ambas as escalas.

Orofacial Function, Articulation Proficiency, and Intelligibility in 5-Year-Old Children Born With Cleft Lip and Palate

OBJECTIVE

To explore and describe orofacial function in 5-year-old children born with clefts affecting the palate and to investigate potential relationship with articulation proficiency and intelligibility.

DESIGN

A prospective cohort study of 88 consecutive patients born with cleft lip and palate (CLP) between July 2009 and June 2011.

PARTICIPANTS

Excluding internationally adopted children and children with no speech production resulted in 52 children with different cleft types and additional malformations, examined at age 5. Data on orofacial function were available for 43 children.

OUTCOME MEASURES

Screening of orofacial function resulted in a profile and a total score, narrow phonetic transcription of test consonants produced a percentage of consonants correct (PCC) score, and ratings of intelligibility by speech and language pathologists (SLPs) and by parents gave 2 estimates. Inter- and intra-transcriber agreement was calculated.

RESULTS

Orofacial dysfunction was found in 37% of children, with results not significantly different between cleft types but significantly more frequent than in children born without CLP. Age-appropriate articulation proficiency was found in 39%, 49% presented below -2 standard deviations. Just above 50% had good intelligibility and were always understood by different communication partners according to both SLP and parent ratings. No significant correlation was found between orofacial dysfunction and PCC or intelligibility.

CONCLUSIONS

Orofacial dysfunction was not found to be an explanatory factor for speech outcome in children born with CLP.

Mean GOSLON Yardstick Scores After 3 Different Treatment Protocols—A Long-term Study of Patients With Unilateral Cleft Lip and Palate

Objectives:

(1) To evaluate dental arch relationships, with the Great Ormond Street, London and Oslo (GOSLON) Yardstick, of participants with Unilateral cleft lip and palate (UCLP) and treated with 1-stage palatal closure with 3 different surgical protocols (2) to compare the mean GOSLON ratings with other CLP centers.

Design:

Retrospective study of medical charts and dental models.

Setting:

Karolinska University Hospital, Stockholm, Sweden.

Participants:

Eighty-seven patients with UCLP operated with 1-stage palatal repair. Thirty-five were operated with Veau-Wardill-Kilner (VWK) technique 1975 to 1986, 31 with minimal incision technique (MIT) from 1987 to 1997, and 21 according to MIT with muscle reconstruction (MITmr) 1998 to 2004.

Interventions:

Dental casts at ages 5 (n = 87), 7 to 8 (n = 27), 10 (n = 81), 16 (n = 61), and 19 (n = 35) years were rated by 10 assessors with the GOSLON Yardstick. Information of other interventions was retrieved from patients’ charts.

Main outcome measures:

Mean GOSLON ratings.

Results:

A total of 82% of the participants were rated as having excellent to satisfactory outcome. Weighted κ statistics for the 10 assessors was good for inter-rater agreement and good/very good for intra-rater agreement.

Conclusions:

The mean GOSLON score in the Stockholm overall material at age 10 was 2.67. The VWK technique resulted in a greater need of orthognathic surgery than the MIT ( P < .01). The MITmr did not produce better dental arch relationships than MIT at age 5 ( P < .05). The best dental arch relationships were found in the MIT group at 10 years, mean 2.58, which is not significantly different from other centers with excellent outcome except Gothenburg and Vienna.

Speech in 5-Year-Olds With Cleft Palate With or Without Cleft Lip Treated With Primary Palatal Surgery With Muscle Reconstruction According to Sommerlad

OBJECTIVE

To evaluate speech in 5-year-olds with cleft palate with or without cleft lip (CP±L) treated with primary palatal surgery in 1 stage with muscle reconstruction according to Sommerlad at about 12 months of age.

DESIGN

Retrospective study.

SETTING

Primary care university hospital.

PARTICIPANTS

Eight 5-year-olds with cleft soft palate (SP), 22 with cleft soft/hard palate (SHP), 33 with unilateral cleft lip and palate, and 17 with bilateral CLP (BCLP).

MAIN OUTCOME MEASURES

Percent oral consonants correct (POCC), percent consonants correct adjusted for age (PCC-A), percent oral errors, percent nonoral errors, and variables related to velopharyngeal function were analyzed from assessments of audio recordings by 3 independent speech-language pathologists.

RESULTS

The median POCC was 75.4% (range: 22.7%-98.9%), median PCC-A 96.9% (range: 36.9%-100%), median percent oral errors 3.4% (range: 0%-40.7%), and median percent nonoral errors 0% (range: 0%-20%), with significantly poorer results in children with more extensive clefts. The SP group had significantly less occurrence of audible nasal air leakage than the SHP and the BCLP groups. Before age 5 years, 1.3% of the children underwent fistula surgery and 6.3% secondary speech improving surgery. At age 5 years, 15% of the total group was perceived as having incompetent velopharyngeal function.

CONCLUSIONS

Speech was poorer in many children with more extensive clefts. Children with CP±L had poorer speech compared to normative data of peers without CP±L, but the results indicated relatively good speech compared to speech of children with CP±L in previous studies.

A Cross-Sectional Study of Speech in 10-Year-Old Children with Cleft Palate: Results and Issues of Rater Reliability

Objectives:

To describe speech based on perceptual evaluation in a group of 10-year-old children with cleft palate. A secondary aim was to investigate the reliability of speech-language pathologists’ perceptual assessment of cleft palate speech.

Design:

Retrospective cross-sectional study in children with cleft palate. External raters made assessments from randomized speech recordings.

Subjects:

Thirty-eight children with unilateral cleft lip and palate (UCLP) or cleft palate only (CPO) and 10 children in a comparison group.

Main Outcome Measures:

Ratings of hypernasality, hyponasality, audible nasal air leakage, weak pressure consonants, and articulation. Exact agreement and weighted kappa values were used for reliability.

Results:

Hypernasality was found in 25% of children with a cleft of the soft palate (CSP), 33% of children with a cleft of the hard and soft palate (CHSP), and 67% of children with a UCLP. Similar results were found for audible nasal air leakage. Articulation errors were found in 6% of the CHSP group and 25% of the UCLP group, whereas no child in the CSP group had articulation errors. The reliability was moderate to good for different variables, with lowest values for hypernasality.

Conclusions:

Speech results in this series seem less satisfactory than those reported in other published international studies, but it is difficult to draw any certain conclusions about speech results because of large methodological differences. Further developments to ensure high reliability of perceptual ratings of speech are called for.

Speech in 10-Year-Olds Born with Cleft Lip and Palate: What Do Peers Say?

Objective

The aim of this study was to explore how 10-year-olds describe speech and communicative participation in children born with unilateral cleft lip and palate in their own words, whether they perceive signs of velopharyngeal insufficiency (VPI) and articulation errors of different degrees, and if so, which terminology they use.

Methods/Participants

Nineteen 10-year-olds participated in three focus group interviews where they listened to 10 to 12 speech samples with different types of cleft speech characteristics assessed by speech and language pathologists (SLPs) and described what they heard. The interviews were transcribed and analyzed with qualitative content analysis.

Results

The analysis resulted in three interlinked categories encompassing different aspects of speech, personality, and social implications: descriptions of speech, thoughts on causes and consequences, and emotional reactions and associations. Each category contains four subcategories exemplified with quotes from the children's statements. More pronounced signs of VPI were perceived but referred to in terms relevant to 10-year-olds. Articulatory difficulties, even minor ones, were noted. Peers reflected on the risk to teasing and bullying and on how children with impaired speech might experience their situation. The SLPs and peers did not agree on minor signs of VPI, but they were unanimous in their analysis of clinically normal and more severely impaired speech.

Conclusions

Articulatory impairments may be more important to treat than minor signs of VPI based on what peers say.

Perceptual Assessment of Velopharyngeal Dysfunction by Otolaryngology Residents

OBJECTIVE

To assess the ability of otolaryngology residents to rate the hypernasal resonance of patients with velopharyngeal dysfunction. We hypothesize that experience (postgraduate year [PGY] level) and training will result in improved ratings of speech samples.

STUDY DESIGN

Prospective cohort study.

SETTING

Otolaryngology training programs at 2 academic medical centers.

SUBJECTS AND METHODS

Thirty otolaryngology residents (PGY 1-5) were enrolled in the study. All residents rated 30 speech samples at 2 separate times. Half the residents completed a training module between the rating exercises, with the other half serving as a control group. Percentage agreement with the expert rating of each speech sample and intrarater reliability were calculated for each resident. Analysis of covariance was used to model accuracy at session 2.

RESULTS

The median percentage agreement at session 1 was 53.3% for all residents. At the second session, the median scores were 53.3% for the control group and 60% for the training group, but this difference was not statistically significant. Intrarater reliability was moderate for both groups. Residents were more accurate in their ratings of normal and severely hypernasal speech. There was no correlation between rating accuracy and PGY level. Score at session 1 positively correlated with score at session 2.

CONCLUSION

Perceptual training of otolaryngology residents has the potential to improve their ratings of hypernasal speech. Length of time in residency may not be best predictor of perceptual skill. Training modalities incorporating practice with hypernasal speech samples could improve rater skills and should be studied more extensively.

A Cross-Sectional Cohort Study of Speech in Five-Year-Olds with Cleft Palate ± Lip to Support Development of National Audit Standards

Objective

To develop national standards for speech outcomes and processes of care for children with cleft palate ± lip and to test the standards using national data.

Design, Setting, and Participants

In this large, multicenter, prospective cohort study, speech recordings of 1110 five-year-olds with cleft palate involvement (born 2001 to 2003) were collected by 12 cleft centers in Great Britain and Ireland. Recordings were analyzed by consensus by specialist speech and language therapists using the Cleft Audit Protocol for Speech-Augmented. Results were benchmarked against evidence-based process and speech outcome standards and statistical analysis undertaken.

Results

From the 1110 children audited, 48% (530) had speech within the normal range. This was not significantly different from the agreed standard of 50% ( P = .20, CI = 45–50%). Sixty-six percent (734) had speech with no evidence of structurally related speech problems or history of speech-related secondary surgery. This was significantly below the standard of 70% ( P =.007, CI = 62–69%). Sixty percent (666) had no serious cleft-related articulation errors. This was significantly better than the agreed standard of 50% ( P < .001, CI = 67–73%). More than 80% of 2-year-olds received a specialist speech and language assessment against a benchmark of 100%.

Conclusions

Developing standards has facilitated more meaningful reporting of speech outcomes and treatment processes. Evidence-based standards were defined and extensively tested, enabling centers to compare their performance with national trends. One 5-year outcome standard was achievable; the other two standards will require modification through the mandatory annual national audit program.

Age-Specific Communication Functioning of Young Children with Cleft Lip and Palate in a South African Database

Objective

To determine the age-specific communication functioning of children with cleft lip and palate (CLP) in the age groups of 1 to 11 months, 12 to 23 months, and 24 to 48 months.

Design

A retrospective, descriptive, cross-sectional survey design was employed.

Participants

Purposive sampling was implemented as a nonrandomized sampling method. The data sets of 227 participants, between the ages of 1 month and 48 months, and their families were investigated.

Setting

The assessment data were extracted from an early communication intervention database at the Clinic for High Risk Babies at the University of Pretoria.

Results

The findings revealed that expressive and receptive language and listening skills presented as the most vulnerable communication areas across all three age groups. The cumulative effect of the risk factors was the greatest in the 12- to 23-month age group, as this group presented with the highest frequency of delayed communication development. Relative strengths were found across all age groups in three areas: average cognitive skills, gross motor development, and displaying an appropriate variety of communication functions.

Conclusions

The findings are confirmed by other studies and suggest that young children with CLP in the 12- to 23-month age group may be the most vulnerable for the emergence of communication delays. The vulnerable areas of communication development should be integrated as goals in a focused early communication intervention approach to the treatment of the young population with CLP.

Occurrence of consonant production errors in liquid phonemes in children with operated cleft lip and palate

Information about the prevalence of consonant production errors, including compensatory articulations (CA), in individuals with cleft lip and palate (CLP) who speak Brazilian Portuguese is limited, particularly regarding liquid sounds. The literature primarily reports the occurrence of CA for plosive and fricative sounds, since occurrence of CAs in sounds that require higher amounts of oral air pressure is expected. While the use of CA during liquid sound production is not expected, clinical experience suggests that individuals with CLP present with inadequate backing, elevation, and anteriorization of the tongue as well as tongue clicks during production of /r/ and /l/.

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

Objective

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

Participants

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

Measures

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

Results

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

Conclusions

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

Cry Melody in 2-Month-Old Infants with and without Clefts

Objective

To investigate cry melody properties in infants with clefts using objective methods and to identify early differences in cry development in relation to infants without clefts that may indicate special developmental risks.

Design

Melody analysis was carried out on cries from the second month of life. The cry properties of infants with a cleft lip and palate (CLP) and infants with a cleft palate only (CP) were quantitatively compared. Both groups were compared to infants without clefts.

Participants

Twenty-one infants with nonsyndromic clefts, including 11 infants with CLP and 10 infants with CP, were compared to 50 healthy controls.

Main Outcome Measures

Frequency spectrograms and melody diagrams of about 7000 cries were analyzed. For each infant's crying, melodic and rhythmic properties were investigated and expressed by appropriate quantitative indices. Based on previous studies, the degree of melody complexity in an infants’ crying was used as an indicator of their present prespeech developmental status.

Results

The cleft groups did not significantly differ from each other with respect to their cry melody development. However, both groups were significantly different from the control group, exhibiting a lower proportion of complex cry melodies and a deviation in rhythmicity. No significant correlation to hearing performances was found that could explain the differences.

Conclusions

Infants with clefts differ in their cry development from infants without clefts at 2 months of life. This early difference occurs before the infants undergo any surgical intervention or other treatment.

Speech Results after One-Stage Palatoplasty with or without Muscle Reconstruction for Isolated Cleft Palate

Objective

To investigate speech outcome between children with isolated cleft palate undergoing palatoplasty with and without muscle reconstruction and to compare speech outcomes between cleft and noncleft children. The number of subsequent velopharyngeal flaps was compared with respect to surgical techniques and cleft extent.

Design

Cross-sectional retrospective study.

Participants

One hundred four children aged 4 years, 0 months to 6 years, 0 months, 33 with isolated cleft of the soft palate, 53 with isolated cleft of the hard and soft palate, and 18 noncleft children.

Interventions

Two primary palate repair techniques: minimal incision technique (MIT) and minimal incision technique including muscle reconstruction (MITmr).

Main Outcome Measures

Perceptual judgment of seven speech parameters assessed on a five-point scale.

Results

No significant differences in speech outcomes were found between MIT and MITmr surgery groups. The number of velopharyngeal flaps was significantly lower after MITmr surgery compared to MIT surgery. The number of flaps was also significantly lower in children with cleft of the soft palate compared to children with cleft of the hard and soft palate. Children with cleft of the soft palate had significantly less glottal articulation and weak pressure consonants compared to children with cleft of the hard and soft palate.

Conclusions

The MITmr surgery technique was not significantly superior to the MIT technique regarding speech outcomes related to velopharyngeal competence, but had fewer velopharyngeal flaps, which is contradictory. Until a larger sample can be studied, we will continue to use MITmr for primary palate repair.

Speech and language development in toddlers with and without cleft palate

OBJECTIVE

The effect of early palate closure on speech and language development in children with cleft palate.

DESIGN

Comparative study.

SETTING

University Medical Center Groningen, Cleft Palate Team (The Netherlands).

MATERIALS AND METHODS

Forty-three toddlers with cleft palate and thirty-two toddlers without cleft palate were analyzed with standardized tests for language comprehension and language production. Moreover articulation and hyper nasality were examined by trained speech therapists.

RESULTS

For language comprehension, language production and articulation there were no significant differences between the children with and without cleft lip and/or palate. This is despite the high percentage of conductive hearing loss (55%) in children with clefts. Significant difference was found for hyper nasality (mean: 35% vs. 0%, p=0.001). In both groups articulation problems raise to a higher percentage than language production problems (63-20%; 24-4%).

CONCLUSIONS

Early surgical treatment is effective for a part of the communicative development, i.e. language development and articulation. Besides conductive hearing loss hyper nasality remains a serious problem in 30-50% of the children with cleft palate. Therefore, speech therapy and pharyngoplasty also are part of the treatment procedure. Because of the high amount articulation problems in all children, standards for articulation development are perhaps too strict. Future research should be carried out after normal variations in articulation development.

A Longitudinal Study of Speech Production in Swedish Children with Unilateral Cleft Lip and Palate and Two-stage Palatal Repair

Objective:

To describe speech production longitudinally in a group of children with unilateral cleft lip and palate (UCLP).

Participants:

Twenty consecutive children with UCLP and nine age-matched children without clefts in a comparison group.

Intervention:

A two-stage palatal repair procedure with soft palate closure at 6 months and hard palate repair at 3 to 4 years.

Main Outcome Measures:

Percent correct consonants (PCC), percent correct places (PCP), and percent correct manners (PCM) at 3, 5, and 7 years of age. Cleft speech errors at the same ages. Previously collected data on number of consonant tokens, consonant types, frequency of occurrence of places and manners of articulation at 18 months.

Results:

PCC and PCP were significantly lower in the UCLP group than in the comparison group at all ages. Number of consonant types and frequency of occurrence of dental plosives at 18 months correlated significantly with PCC at age 3. A high frequency of velar plosives at 18 months correlated significantly with a high prevalence of retracted oral articulation (dental/alveolar to palatal or velar) at both 3 and 5 years of age.

Conclusions:

The UCLP group performed worse than the comparison group at all ages. A high occurrence of dental plosives as well as a high number of consonant types in babbling and first words seem to be good indicators for better consonant production in later speech. The same prevalence of retracted oral articulation as in previous studies is attributed to the surgical technique.