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

Using Artificial Intelligence for Assessment of Velopharyngeal Competence in Children Born With Cleft Palate With or Without Cleft Lip

OBJECTIVE

Development of an AI tool to assess velopharyngeal competence (VPC) in children with cleft palate, with/without cleft lip.

DESIGN

Innovation of an AI tool using retrospective audio recordings and assessments of VPC.

SETTING

Two datasets were used. The first, named the SR dataset, included data from follow-up visits to Skåne University Hospital, Sweden. The second, named the SC + IC dataset, was a combined dataset (SC + IC dataset) with data from the Scandcleft randomized trials across five countries and an intercenter study performed at six Swedish CL/P centers.

PARTICIPANTS

SR dataset included 153 recordings from 162 children, and SC + IC dataset included 308 recordings from 399 children. All recordings were from ages 5 or 10, with corresponding VPC assessments.

INTERVENTIONS

Development of two networks, a convolutional neural network (CNN) and a pre-trained CNN (VGGish). After initial testing using the SR dataset, the networks were re-tested using the SC + IC dataset and modified to improve performance.

MAIN OUTCOME MEASURES

Accuracy of the networks' VPC scores, with speech and language pathologistś scores seen as the true values. A three-point scale was used for VPC assessments.

RESULTS

VGGish outperformed CNN, achieving 57.1% accuracy compared to 39.8%. Minor adjustments in data pre-processing and network characteristics improved accuracies.

CONCLUSIONS

Network accuracies were too low for the networks to be useful alternatives for VPC assessment in clinical practice. Suggestions for future research with regards to study design and dataset optimization were discussed.

Speech Outcomes in 5-Year-Old Korean Children with Bilateral Cleft Lip and Palate

Background  Among the cleft types, bilateral cleft lip and palate (BCLP) generally requires multiple surgical procedures and extended speech therapy to achieve normal speech development. This study aimed to describe speech outcomes in 5-year-old Korean children with BCLP and examine whether normal speech could be achieved before starting school. Methods  The retrospective study analyzed 52 children with complete BCLP who underwent primary palatal surgery at a tertiary medical center. Three speech-language pathologists made perceptual judgments on recordings from a speech follow-up assessment of 5-year-old children. They assessed the children's speech in terms of articulation, speech intelligibility, resonance, and voice using the Cleft Audit Protocol for Speech-Augmented-Korean Modification. Results  The results indicated that at the age of five, 65 to 70% of children with BCLP presented articulation and resonance within normal or acceptable ranges. Further, seven children with BCLP (13.5%) needed both additional speech therapy and palatal surgery for persistent velopharyngeal insufficiency and speech problems even at the age of five. Conclusion  This study confirmed that routine follow-up speech assessments are essential as a substantial number of children with BCLP require secondary surgical procedures and extended speech therapy to achieve normal speech development.

Speech in 7- and 10-year-olds born with a unilateral cleft lip and palate: a continued prospective Swedish intercentre study

The aim of this study was to report longitudinal speech results in consecutively selected children from each of the six cleft centres in Sweden and to compare the results between centres. The children were born with a non-syndromic unilateral cleft lip and palate, and results from the same cohort at 5 years of age have previously been reported. Background data on medical care in terms of surgery, speech therapy, and hearing between 5 and 10 years of age were collected. Speech recordings of 56 children at 7 years and 54 at 10 years of age were blindly and independently assessed by four speech-language pathologists experienced in cleft palate speech. This resulted in measures of percent consonant correct (PCC) and perceived velopharyngeal competence rated on a three-tier scale. No statistically significant differences were found between centres. PCC scores at 7 years of age ranged from 44-100% (median 97.5) and at 10 years of age from 86-100% (median 100). Competent or marginally incompetent velopharyngeal function was found in 95% of the 7-year-olds and 98% of the 10-year-olds. Speech results were slightly better than previous reports of speech in children born with a unilateral cleft lip and palate.

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.

Long-term speech outcome after anterior distraction osteogenesis of the maxilla in patients with cleft lip and palate

Advancement of the maxilla may increase the distance between the soft palate and the posterior pharyngeal wall in patients with cleft lip and palate, implying a risk of velopharyngeal dysfunction. The aim was to evaluate long-term speech outcome in a consecutive series of patients treated with distraction osteogenesis (DO). Fourteen out of the 16 patients agreed to participate. A long-term speech follow-up was performed 1.5 to 13.5 years after DO. For two participants, audio recordings before DO were missing, and for another one, it was incomplete. The percentage of consonants correct (PCC) based on phonetic transcription and perceived velopharyngeal competence rated on a three-point scale were assessed before and after DO by three independent judges, based on audio recordings of reading of standardised sentences. Also, the participants were asked how they perceived their speech after DO. Changes in PCC were insignificant. Four participants perceived deteriorated speech related to DO. In two cases, the subjective deterioration did not correlate to results from perceptual assessment. In two others, the subjective deterioration correlated with the perceptual assessment, and the velopharyngeal function was judged as being incompetent after DO. After secondary velopharyngeal surgery, velopharyngeal function improved to competent in one case and marginally incompetent in the other. The results need to be interpreted with caution due to methodological limitations but indicate that some patients develop deteriorated velopharyngeal function after DO. The impact on articulation needs to be further explored. It is important that patients are informed before treatment of the risk of velopharyngeal dysfunction after DO.

Speech and Burden of Secondary Surgical Interventions Following One-Stage Repair of Unilateral Cleft Lip and Palate and Alveolar Bone Grafting Performed at Different Timings

A comprehensive assessment of the treatment outcome in cleft lip and palate involves evaluating speech and the impact of speech-correcting surgical interventions. This retrospective case-control study compared the speech outcomes of 37 boys and 19 girls with unilateral cleft lip and palate (UCLP) who underwent one-stage cleft repair at an average age of 8.1 months and alveolar bone grafting either before or after 6 years of age, with a non-cleft control group at an average age of 10 years. Two experienced speech and language pathologists conducted perceptual speech assessments using a specialized test of 27 sentences designed for Polish-speaking cleft patients. The results revealed that 5.3% had severe hypernasality, 1.8% had severely impaired speech intelligibility, 10.7% exhibited retracted compensatory articulations, and 7.1% displayed facial grimacing. Mild hyponasality was observed in 12.3% of patients, while 16.1% exhibited voice abnormalities. Additionally, 12.5% of patients required orofacial fistula repairs, 3.6% underwent pharyngoplasties, and 28.6% received ear ventilation tube insertions. The study indicates that speech abnormalities in UCLP patients were relatively infrequent and not highly severe, suggesting that the primary UCLP repair method presented effectively reduced the need for further surgical interventions, leading to positive speech outcomes.

Speech Symptoms of Velopharyngeal Insufficiency and the Incidence of Secondary Speech Surgery in 10-Year-Old Children With Unilateral Cleft Lip and Palate: Comparison of 2 Randomized Surgical Methods for Primary Palatal Surgery

OBJECTIVE

To compare speech symptoms of velopharyngeal insufficiency (VPI) and incidence of secondary speech surgery in 10-year-old Finnish children with unilateral cleft lip and palate (UCLP) following primary palatal surgery using 2 surgical methods.

DESIGN

Single center analysis within the Scandcleft multicenter randomized controlled trial of primary surgery for UCLP.

MATERIALS AND METHODS

Patients comprised 79 nonsyndromic 10-year-old children with UCLP. Two randomized surgical methods were used in the primary palatal surgery: soft palate closure at 4 months and hard palate closure at 12 months (Arm A) and closure of both the soft and hard palate at 12 months (Arm C). Speech symptoms of VPI were analyzed from standardized video recordings by 2 experienced speech pathologists. The incidences of surgery for correcting VPI, fistula closure, and speech therapy were evaluated retrospectively from patient records.

RESULTS

No differences in speech symptoms of VPI, need for VPI surgery or speech therapy were found between the surgical methods. Of all 79 children, 33% had had VPI surgery and 61% had speech therapy. The number of fistulas was significantly higher in Arm A (25%) than in Arm C (2%). Moderate to severe speech symptoms of VPI (hypernasality, continuous nasal air leakage, weak pressure consonants, and/or compensatory articulation) were found in 11% of the children.

CONCLUSION

No differences were present between groups in speech symptoms of VPI or need for VPI surgery or speech therapy between the 2 surgical methods. One third of the children had undergone VPI surgery. Most of the children (89%) had good or relatively good speech.

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.

Prognosis of Continuous Positive Airway Pressure Treatment to Velopharyngeal Insufficiency: Preliminary Study

BACKGROUND

Cleft palate is a congenital malformation that causes hypernasality and decreases the intelligibility of pronunciation and leads to velopharyngeal insufficiency. It causes difficulty in language development. Many studies and treatments have been conducted to reduce this problem, but there are limitations. In this study, the effect obtained through continuous positive airway pressure (CPAP) treatment was analyzed by statistical methods.

METHODS

From May 2012 to December 2018, using patient demographics, computed tomography (CT) scan, and nasalance test was performed on 25 patient groups treated with CPAP devices for 8 weeks to confirm the effect after 6 months.

RESULTS

After CPAP treatment in a total of 25 patients, 13 patients had a therapeutic effect. The average age of the patient group with treatment effect (effective group [EG]) was 51.2months, and the patient group with no treatment effect (ineffective group [iG]) was 73.6 months. (P < 0.05). In CT data analysis, the highest palatal arch point was 6.31 mm in EG and 7.36 mm in IG, which was lower in EG (P < 0.01), and the distance from incisive foramen to posterior pharyngeal wall was 41.39 mm in EG and 49.07 mm in IG (P < 0.05).

CONCLUSIONS

Through the statistical analysis, the group of patients who were effective in treatment had a low age at the beginning of treatment, the height of highest palatal arch point was low on CT data, and the length of distance from incisive foramen to posterior pharyngeal wall was short. It will be helpful to set the CPAP treatment patient group with respect to the results and age and CT data when treating VPI patients.

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

OBJECTIVE

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

DESIGN

Prospective study.

PARTICIPANTS

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

MAIN OUTCOME MEASURES

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

RESULTS

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

CONCLUSIONS

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

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 Outcomes Comparison Between Adult Velopharyngeal Insufficiency and Patients With Unrepaired Cleft Palate

OBJECTIVE

This study compared the speech outcomes of adult velopharyngeal insufficiency patients and adult cleft palate (ACP) patients, and explored whether there was any difference in the phonological level of these 2 types of patients.

METHODS

Perceptual evaluation was used to assess speech intelligibility, hypernasality and compensatory articulation in 89 adult patients with velopharyngeal insufficiency and 35 adult patients with unrepaired cleft palate. Each group was divided into complete cleft palate and incomplete cleft palate (including submucous cleft palate). The phonological differences were compared between the 2 groups of patients and 2 types of cleft palate.

RESULTS

The mean speech intelligibility was 43.04% in velopharyngeal insufficiency group and 32.87% in ACP group. There was a significant difference in speech intelligibility between the 2 groups by T test, t = 2.916 (P < 0.01), speech intelligibility between 2 types of cleft palate was no significant difference. Also, there was a significant difference between the 2 groups in the constitution of hypernasality degree by Chi-Square test, x2 = 31.650 (P < 0.01), compensatory articulation were present in 74.3% ACP patients (26/35) and 47.2% velopharyngeal insufficiency patients (42/89), x2 = 7.446 (P < 0.01), there was a significant difference in incidence of compensatory articulation between the 2 groups.

CONCLUSIONS

Adult patients with unpaired cleft palate present an even worse speech intelligibility and hypernasality degree than velopharyngeal insufficiency patients after cleft palate repair, regardless of the cleft type. Additionally, patients in ACP group have a higher incidence of compensatory articulation than that in incomplete cleft palate group. In sequenced treatments of cleft lip and palate, evaluation and treatment of speech disorders cannot be ignored.

Prevalence of Reading Difficulties in 9- to 10-Year Old Children in Sweden Born With Cleft Palate

OBJECTIVE

To investigate the prevalence of reading difficulties in children born with cleft palate at ages 9 and 10 in Sweden.

DESIGN

Using a cross-sectional design, a parental questionnaire assessing dyslexia-like reading difficulties (Short Dyslexia Scale, SDS) was administered together with separate questions regarding background data.

PARTICIPANTS

Families with a child born with overt cleft palate with or without cleft lip in 4 regions of Sweden. A total of 245 families were approached of which 138 families responded. Data from 136 (56%) were complete with information on cleft type and could be analyzed.

RESULTS

Twenty-two percent (95% CI, 15-30) of the whole study group displayed risk for dyslexic reading difficulties on the SDS corresponding to the 7th to 10th percentiles in the population. Children with cleft palate only had a significantly higher prevalence of reading difficulties (37%) compared to children with unilateral cleft palate (19%) and bilateral cleft palate (10%). The frequency of reading difficulties in participants with comorbidity was 32%. Among a subgroup with reported comorbidity in areas of attention, language, and learning problems, there was a 2.5 times higher risk of reading disability compared to participants without this reported comorbidity.

CONCLUSION

The prevalence of reading difficulties in the cleft palate population was higher than in the general population. Results showed that co-occurring difficulties were common in the cleft group and that reading difficulties often appear together with other, co-occurring neurodevelopmental difficulties.

Global and communicative development skills in preschool children with cleft lip and palate

IMPORTANCE

Cleft lip and palate (CLP) is globally among the most common childhood malformations. This disorder impacts childhood development, including speech and language, and affects children worldwide.

OBJECTIVE

To analyze child development skills (adaptive fine motor, gross motor, personal-social, and language) in preschool children with isolated CLP compared with children without this malformation.

METHODS

The participants included an experimental group of 27 children with isolated CLP and a comparison group of 27 children without CLP aged between 48 and 59 months. The groups were evaluated using two instruments: the Denver Developmental Screening Test II (DDST-II) and the Avaliação do Desenvolvimento da Linguagem (ADL-Language Development Assessment). Data were analyzed by descriptive and inductive analyses, using the Student's t-test and the Mann-Whitney test, at a significance level of P ˂ 0.05.

RESULTS

All children in the comparison group performed within normal standards for their age range in the DDST-II and the ADL. The worst performance in the experimental group was observed in language skills, followed, in declining order, by adaptive fine motor, personal-social, and gross motor as measured by the DDST-II. Children with isolated CLP also performed poorly in receptive, expressive, and global language in the ADL. No statistically significant differences were observed in the experimental group's scores for the ADL and the DDST-II.

INTERPRETATION

Developmental skill levels were below expectations for children of this age with isolated CLP.

Pharyngeal bulb prosthesis and speech outcome in patients with cleft palate

Introduction

Individuals with cleft palate can present with velopharyngeal dysfunction after primary palatoplasty and require a secondary treatment due to insufficiency. In these cases, the pharyngeal bulb prosthesis can be used temporarily while awaiting secondary surgery.

Objective

This study aimed to investigate the outcome of treatment of hypernasality with pharyngeal bulb prosthesis in patients with history of cleft palate presenting with velopharyngeal insufficiency after primary palatal surgery. We hypothesized that the use of the pharyngeal bulb prosthesis is an effective approach to eliminate hypernasality related to velopharyngeal insufficiency in patients with cleft palate.

Methods

Thirty speakers of Brazilian Portuguese (15 males and 15 females) with operated cleft palate, ages ranging from 6 to 14 years (mean: 9 years; SD = 1.87 years), participated in the study. All patients were fitted with a pharyngeal bulb prosthesis to manage velopharyngeal insufficiency while they were awaiting corrective surgery to be scheduled. Auditory-perceptual analysis of speech recorded in the conditions with and without pharyngeal bulb prosthesis were obtained from three listeners who rated the presence or absence of hypernasality for this study.

Results

Seventy percent of the patients eliminated hypernasality while employing the pharyngeal bulb prosthesis, while 30% still presented with hypernasality. The comparison was statistically significant (p < 0.001).

Conclusion

The use of the pharyngeal bulb prosthesis is an effective approach to eliminate hypernasality related to velopharyngeal insufficiency.

[Formula: see text] Neuropsychological functioning and its relationship with brain anatomical measures of children and adolescents with non-syndromic cleft lip and palate

BACKGROUND

Children and adolescents with non-syndromic cleft lip and palate (NSCLP) show cognitive performance below expected. This difficulty can be associated with alterations in the cortical thickness and volume of brain regions. The aim of this study was to investigate anatomical brain characteristics and their relationship with the neuropsychological scores of children and adolescents with NSCLP. Methods: Twenty-four children and adolescents with ages from 10 to 16 years and 11 months (12 with a diagnosis of NSCLP; 12 with typical development) were enrolled. Neuropsychological tests were administered and high-resolution, structural magnetic resonance imaging (MRI) was performed in a 1.5 T scanner. Results: Compared to the control group, NSCLP individuals showed intellectual (p = 0.006) and cognitive (p = 0.003) impairment, as well as deficits in subdomains of executive functions (sustained attention, working memory, and cognitive planning). The morphological analysis showed reduced volumes and cortical thickness in temporal, parietal, and frontal regions, in both hemispheres, of the NSCLP group. Significant, strong associations of structural alterations and cognitive performance were observed. Conclusions: Our study provided strong evidence of the relationship between brain development in children and adolescents with NSCLP, and their neuropsychological profile. This relationship is characterized by a malfunction of associative areas of the brain, such as parieto-temporo-occipital, frontoparietal, and prefrontal regions.

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.

Analysis of oral-nasal balance after intensive speech therapy combined with speech bulb in speakers with cleft palate and hypernasality

OBJECTIVE

To evaluate the efficacy of the combination of a speech bulb with an intensive speech therapy program in hypernasal participants with cleft palate.

METHODS

Twenty hypernasal speakers with cleft palate (12 females and 8 males, median age 28.45 years), who were wearing speech bulbs underwent an intensive speech therapy program of 45 sessions over 3 weeks. Three experienced speech-language pathologists rated the participants' speech recordings before and after intensive speech therapy, with and without the speech bulb. Nasometric recordings and long-term averaged spectra were also analyzed using repeated-measures ANOVAs.

RESULTS

The ANOVA of the hypernasality ratings showed significant effects of therapy [F (1,19) = 15.97; p < .001], speech bulb [F(1,190 = 28.54, p < .001] and a therapy -speech bulb interaction effect [F(1.19) = 22.30, p < 0.001]. The most favorable listener ratings of hypernasality were obtained post-therapy when participants were wearing their speech bulbs. Without the speech bulb, intensive speech therapy by itself did not result in a significant improvement. With speech bulb, nasalance scores for high [F (1,19) = 14.07, p < .001] and low pressure [F (1,19) = 14.84, p < .001] sentences were significantly lower post-therapy, providing preliminary evidence that an intensive speech therapy program may enhance the effect of a speech bulb. Before and after comparisons of individual nasalance profiles demonstrated variable improvement in 15 participants, no progress in 2 participants and more severe hypernasality after therapy in 3 participants. Long-term averaged spectra corroborated the findings of the perceptual analysis. Based on a frequency bin from 201 to 300 Hz, there was a significant within-subject effect for with and without speech bulb [F(1, 18) = 4.54, p = .047] as well as for before vs. after session [F (1,18) = 7.14, p = .015].

CONCLUSION

The speech bulb in combination with intensive speech therapy resulted in improved oral-nasal balance for the majority of participants. More research is needed to investigate long-term outcomes as well as individual factors contributing to therapy success.

Internationally Adopted Children With Unilateral Cleft Lip and Palate-Consonant Proficiency and Perceived Velopharyngeal Competence at the Age of 5

OBJECTIVE

To compare consonant proficiency, consonant errors, and the perceived velopharyngeal (VP) competence in internationally adopted (IA) children with unilateral cleft lip and palate (UCLP) and nonadopted (NA) children with the same cleft-palate type at age 5.

DESIGN

Case-control study based on phonetic transcriptions of standardized speech recordings of 5-year-olds at a tertiary hospital.

PARTICIPANTS

Twenty-five IA children were compared to 20 NA children. All consecutive patients at a cleft lip and palate center participated.

MAIN OUTCOME MEASURE(S)

Consonant proficiency was measured using percentage consonants correct, percentage consonants correct-adjusted for age, percentage correct place, percentage correct manner, and consonant inventory. Cleft speech characteristics (CSCs), developmental speech characteristics (DSCs), and the perceived VP competence were also measured.

RESULTS

The IA children had significantly lower values for all consonant proficiency variables (p < .05) and a smaller consonant inventory (p = .001) compared to the NA children. The IA children had a higher frequency of CSCs (IA = 84%, NA = 50%, p < .05) and DSCs (IA = 92%, NA = 65%, p = .057), and twice as many IA children as NA children had perceived VP incompetence (IA = 52%, NA = 25%, p = .17).

CONCLUSIONS

Severe speech disorder was more common in IA children than in NA children at age 5. Most importantly, the speech disorders seem to be not only cleft-related. More detailed speech assessments with a broader focus are needed for IA children with UCLP. Longitudinal studies are recommended to further investigate the impact of speech difficulties in IA children's daily lives.

Reliability of Speech Variables and Speech-Related Quality Indicators in the Swedish Cleft Lip and Palate Registry

OBJECTIVE

To assess the reliability of speech variables and speech-related quality indicators in the Swedish quality registry for cleft lip and palate (CLP).

DESIGN

Retrospective study.

SETTING

Primary care university hospitals.

PARTICIPANTS

Fifty-two 5-year-old children with unilateral CLP and 41 with bilateral CLP.

MAIN OUTCOME MEASURES

Registry data for "percent nonoral errors" and "perceived velopharyngeal competence" (VPC) were compared to reassessments by 4 independent judges based on audio recordings. Interjudge agreement for "percent consonants correct" (PCC) and the reliability of 3 quality indicators were also assessed. Agreement was calculated with single measures intraclass correlation coefficient (ICC) for articulation outcomes, quadratic weighted κ and ICC for VPC, and percentage agreement and κ for quality indicators.

RESULTS

When the agreement between registry data and the judges' reassessments was assessed, the ICC was 0.79 for percent nonoral errors. For VPC, the κ coefficient was 0.66 to 0.75 and the ICC was 0.73. Interjudge agreement for PCC calculated with ICC was 0.85. For the quality indicator "proportion of children with ≥86% correct consonants," all 4 judges were in agreement for 72% of the cases. For "proportion of children without nonoral speech errors" and "proportion of children with competent or marginally incompetent velopharyngeal function," the agreement between registry data and the 4 judges was 89% and 85%, respectively.

CONCLUSIONS

The results indicate that registry data on PCC, percent nonoral errors, VPC, and the quality indicators "proportion of children without nonoral speech errors" and "proportion of children with competent or marginally incompetent velopharyngeal function" are reliable.

Scandcleft Project Trial 2-Comparison of Speech Outcome in 1- and 2-Stage Palatal Closure in 5-Year-Olds With UCLP

OBJECTIVE

To investigate in-depth speech results in the Scandcleft Trial 2 with comparisons between surgical protocols and centers and with benchmarks from peers without cleft palate.

DESIGN

A prospective randomized clinical trial.

SETTING

Two Swedish and one Finnish Cleft Palate center.

PARTICIPANTS

One hundred twelve participants were 5-years-old born with unilateral cleft lip and palate randomized to either lip repair and soft palate closure at 4 months and hard palate closure at 12 months or lip repair at 3 to 4 months (Arm A), or a closure of both the soft and hard palate at 12 months (Arm C).

MAIN OUTCOME MEASURES

A composite measure dichotomized into velopharyngeal competency (VPC) or velopharyngeal incompetency (VPI), overall assessment of velopharyngeal function (VPC-Rate), percentage of consonants correct (PCC score), and consonant errors. In addition, number of speech therapy visits, average hearing thresholds, and secondary surgeries were documented to assess burden of treatment.

RESULTS

Across the trial, 53.5% demonstrated VPC and 46.5% VPI with no significant differences between arms or centers. In total, 27% reached age-appropriate PCC scores with no statistically significant difference between the arms. The Finnish center had significantly higher PCC scores, the Swedish centers had higher percentages of oral consonant errors. Number of speech therapy visits was significantly higher in the Finnish center.

CONCLUSION

At age 5, poor speech outcomes with some differences between participating centers were seen but could not be attributed to surgical protocol. As one center had very few participants, the results from that center should be interpreted with caution.

Velopharyngeal Closure and Resonance in Children Following Early Cleft Palate Repair: Outcome Measurement

Introduction Timing of cleft palate repair and the method of speech outcome measurement in children with cleft lip and palate are much debated topics. The associated problems and quality of life in these children depend on the timing of the surgery.

Aim The aim of this study was to investigate the velopharyngeal (VP) function and resonance parameters in children following early cleft palate repair.

Method A total of 25 Kannada-speaking children with early repaired cleft palate were subjected to speech assessment and videofluoroscopic assessment. Perceptual speech parameters measured were severity of hypernasality and presence of nasal air emission. Videofluoroscopy was interpreted in terms of closure ratios to predict the severity of VP dysfunction.

Results The analysis of videofluoroscopic images indicated that 48% of children had complete VP closure and 52% had perceptually normal resonance. A good correlation was found between the closure ratio and hypernasality.

Conclusion Understanding the perceptual speech parameters and their structural correlates for outcome measurement will give better evidence for refining the existing treatment protocols. Data on a larger population are warranted for establishing predictors of optimum speech outcome.

Effects of Error Experience on Learning to Lower Speech Nasalance Level

Purpose This research aims to examine the effects of error experience when learning to speak with lowered nasalance level. Method A total of 45 typical speakers were instructed to learn to lower speech nasalance level in either an errorless (restricted possibility for committing errors) or an errorful (unrestricted possibility for committing errors) learning condition. The nasality level of the participants' speech was measured by a nasometer and quantified by nasalance scores (in percent). Errorless learners practiced producing speech with lowered nasalance level with a threshold nasalance score of 50% (the easiest target) at the beginning, which gradually decreased to a threshold of 10% (the most difficult target) at the end. The same set of threshold targets was presented to errorful learners, but in reverse order. Errors were defined by the proportion of speech, with a nasalance score exceeding the threshold. Retention and transfer tests were administered. Results Errorless learners displayed fewer errors and lower mean nasalance scores than errorful learners during the acquisition phase. Furthermore, errorless learners achieved lower mean nasalance scores than errorful learners in the retention and transfer tests. Conclusion These results suggest that errorless learning is more effective than errorful learning and that error experience has a detrimental effect on the acquisition of a novel speech motor task that requires minimization of the nasality level. Errorless learning may be a useful paradigm for the intervention and management of hypernasality in clinical settings where behavioral treatments are needed.

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.

Associations Between Hypernasality, Intelligibility, and Language and Reading Skills in 10-Year-Old Children With a Palatal Cleft

Background:

This study investigated the associations between hypernasality and intelligibility, and language and reading skills in 10-year old children with a cleft palate ± lip.

Design:

Cross-sectional data collected during routine assessments of speech and language in a centralized treatment setting.

Participants:

Children aged 10, born with cleft palate ± lip from 4 birth cohorts (N = 123).

Outcome Measures:

Hypernasality and intelligibility: Swedish Articulation and Nasality Test-N; language: Language 6-16 (Sentence recall, Serial recall, Vocabulary); reading: word chain test and reading comprehension test.

Results:

A total of 71.3% of the children had no occurrence of hypernasality and 82.8% had intelligibility scores within the normal range. For all children with hypernasality and intelligibility within the normal range, reading and language scores were also within normal ranges. Children with presence of hypernasality had significantly lower language skills, with mean scores within the lower normal range. Children with reduced intelligibility had lower scores on reading comprehension.

Conclusions:

The findings highlight a possible association between hypernasality and language skills, and intelligibility and reading skills. Cleft teams should consider routine assessments of language and reading skills in children with speech impairment, in order to identify potential needs for intervention as early as possible.

Child development skills and language in toddlers with cleft lip and palate

INTRODUCTION

Children born with cleft lip and palate (CLP) are exposed to several risk factors for developmental delay.

METHODS

This cross-sectional and descriptive study compared the performance of gross motor, adaptive fine motor, social-personal and language skills in children with non-syndromic cleft lip and palate (age = 36-47 months, n = 30) matched as to chronological age and gender. The evaluation instruments were Denver Developmental Screening Test II and MacArthur Communicative Development Inventory - part D, employed for the receptive and expressive vocabulary checklist. Intergroup comparisons were performed using t tests and Chi-square tests. The Pearson correlation coefficient was used to verify the inter-category correlation (p ≤ 0.05).

RESULTS

There was statistically significant difference in gross motor, adaptive fine motor, and language skills, both in receptive and expressive aspects, in the comparison between groups. In the personal-social area, children with CLP presented performance below the expected, without statistically significant difference between groups.

CONCLUSIONS

Children with CLP are at risk for developmental disorders and should be monitored from early childhood to minimize the deleterious effects of this risk condition.

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.

Reliability of Hypernasality Rating

Objective:

To compare reliability in auditory-perceptual assessment of hypernasality for 3 different methods and to explore the influence of language background.

Design:

Comparative methodological study.

Participants and Materials:

Audio recordings of 5-year-old Swedish-speaking children with repaired cleft lip and palate consisting of 73 stimuli of 9 nonnasal single-word strings in 3 different randomized orders. Four experienced speech-language pathologists (2 native speakers of Brazilian–Portuguese and 2 native speakers of Swedish) participated as listeners. After individual training, each listener performed the hypernasality rating task. Each order of stimuli was analyzed individually using the 2-step, VISOR and Borg centiMax scale methods.

Main Outcome Measures:

Comparison of intra- and inter-rater reliability, and consistency  for each method within language of the listener and between listener languages (Swedish and Brazilian–Portuguese).

Results:

Good to excellent intra-rater reliability was found within each listener for all methods, 2-step: κ = 0.59-0.93; VISOR: intraclass correlation coefficient (ICC) = 0.80-0.99; Borg centiMax (cM) scale: ICC = 0.80-1.00. The highest inter-rater reliability was demonstrated for VISOR (ICC = 0.60-0.90) and Borg cM-scale (ICC = 0.40-0.80). High consistency within each method was found with the highest for the Borg cM scale (ICC = 0.89-0.91). There was a significant difference in the ratings between the Swedish and the Brazilian listeners for all methods.

Conclusions:

The category-ratio scale Borg cM was considered most reliable in the assessment of hypernasality. Language background of Brazilian–Portuguese listeners influenced the perceptual ratings of hypernasality in Swedish speech samples, despite their experience in perceptual assessment of cleft palate speech disorders.

Problems With Reliability of Speech Variables for Use in Quality Registries for Cleft Lip and Palate—Experiences From the Swedish Cleft Lip and Palate Registry

Objective:

To test the reliability of the speech data in the Swedish quality registry for cleft lip and palate.

Design:

Retrospective study.

Setting:

Primary care university hospital.

Participants:

Ninety-four children born with cleft palate with or without cleft lip between 2005 and 2009 who had been assessed and registered in the quality registry at the age of 5 years.

Main Outcome Measures:

Data in the registry on percent oral consonants correct, percent oral errors, percent nonoral errors, perceived velopharyngeal function (PVPF), and intelligibility were compared with results based on reassessments by 3 independent raters from audio recordings. Agreement was calculated by the intraclass correlation coefficient (ICC), quadratic weighted kappa, and percentage agreement.

Results:

Absolute agreement calculated by average measures ICC for percent oral consonants correct, percent oral errors, and percent nonoral errors was above >0.90. Single measures ICC for percent oral consonants correct was 0.82, for percent oral errors 0.69, and for percent nonoral errors 0.83. The kappa coefficient for PVPF was 0.5 to 0.59 and for intelligibility 0.65 to 0.77. Exact percentage agreement for PVPF was 33% and for intelligibility 47.8%.

Conclusions:

The data on oral consonants correct and nonoral errors in the quality registry seem to be reliable. The data on oral errors, PVPF, and intelligibility should be interpreted with caution. If differences among treatment centers are detected, one should go back and examine the collected raw data before drawing any definitive conclusions about treatment outcome.

Incidence of Speech-Correcting Surgery in Children With Isolated Cleft Palate

Objective:

Speech-correcting surgeries (pharyngoplasty) are performed to correct velopharyngeal insufficiency (VPI). This study aimed to analyze the need for speech-correcting surgery in children with isolated cleft palate (ICP) and to determine differences among cleft extent, gender, and primary technique used. In addition, we assessed the timing and number of secondary procedures performed and the incidence of operated fistulas.

Design:

Retrospective medical chart review study from hospital archives and electronic records.

Participants:

These comprised the 423 consecutive nonsyndromic children (157 males and 266 females) with ICP treated at the Cleft Palate and Craniofacial Center of Helsinki University Hospital during 1990 to 2016.

Results:

The total incidence of VPI surgery was 33.3% and the fistula repair rate, 7.8%. Children with cleft of both the hard and soft palate (n = 300) had a VPI secondary surgery rate of 37.3% (fistula repair rate 10.7%), whereas children with only cleft of the soft palate (n = 123) had a corresponding rate of 23.6% (fistula repair rate 0.8%). Gender and primary palatoplasty technique were not considered significant factors in need for VPI surgery. The majority of VPI surgeries were performed before school age. One fifth of patients receiving speech-correcting surgery had more than one subsequent procedure.

Conclusion:

The need for speech-correcting surgery and fistula repair was related to the severity of the cleft. Although the majority of the corrective surgeries were done before the age of 7 years, a considerable number were performed at a later stage, necessitating long-term observation.

The Difference in Cervical Vertebral Skeletal Maturation between Cleft Lip/Palate and Non-Cleft Lip/Palate Orthodontic Patients

Objective

The aim was to evaluate differences in the cervical vertebral skeletal maturity of unilateral cleft lip and palate (UCLP) and non-cleft lip/palate (non-CLP) Saudi male orthodontic patients.

Method

This cross-sectional multicenter study took place at the dental school, King Saud University and King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia, between October 2014 and September 2015. The records of Saudi male orthodontic patients with UCLP (n = 69) were collected. Cervical vertebral maturation was assessed using their cephalometric radiographs. The records of 138 age-matched non-CLP Saudi male orthodontic patients served as controls.

Results

There was a significant difference in skeletal maturity between the UCLP and non-CLP groups, as evident in the delayed skeletal development among the UCLP participants. Moreover, pubertal growth spurt onset was significantly earlier in the non-cleft participants in comparison with the UCLP participants (p = 0.009).

Conclusions

There is delayed skeletal maturity among the UCLP Saudi male population in comparison with their non-CLP age-matched peers.

Scandcleft randomised trials of primary surgery for unilateral cleft lip and palate: 4. Speech outcomes in 5-year-olds - velopharyngeal competency and hypernasality

BACKGROUND AND AIM

Adequate velopharyngeal function and speech are main goals in the treatment of cleft palate. The objective was to investigate if there were differences in velopharyngeal competency (VPC) and hypernasality at age 5 years in children with unilateral cleft lip and palate (UCLP) operated on with different surgical methods for primary palatal repair. A secondary aim was to estimate burden of care in terms of received additional secondary surgeries and speech therapy.

DESIGN

Three parallel group, randomised clinical trials were undertaken as an international multicentre study by 10 cleft teams in five countries: Denmark, Finland, Sweden, Norway, and the UK.

METHODS

Three different surgical protocols for primary palatal repair were tested against a common procedure in the total cohort of 448 children born with a non-syndromic UCLP. Speech audio and video recordings of 391 children (136 girls, 255 boys) were available and perceptually analysed. The main outcome measures were VPC and hypernasality from blinded assessments.

RESULTS

There were no statistically significant differences between the prevalences in the arms in any of the trials. VPC: Trial 1, A: 58%, B: 61%; Trial 2, A: 57%, C: 54%; Trial 3, A: 35%, D: 51%. No hypernasality: Trial 1, A: 54%, B: 44%; Trial 2, A: 47%, C: 51%; Trial 3, A: 34%, D: 49%.

CONCLUSIONS

No differences were found regarding VPC and hypernasality at age 5 years after different methods for primary palatal repair. The burden of care in terms of secondary pharyngeal surgeries, number of fistulae, and speech therapy visits differed.

TRIAL REGISTRATION

ISRCTN29932826.

A non-language-specific speech test to evaluate the speech of cleft patients from different language and cultural backgrounds - A pilot study

Cleft speech tests are not universally available. We developed a tool to fill this gap, especially in the context of a cleft mission setting. We performed a pilot study to evaluate the test's ability to differentiate between the speech of cleft patients and healthy individuals from three different language backgrounds. We used 78 made-up, nonsensical syllables to evaluate hypernasality, nasal emissions, and consonant errors. Cleft (n = 41) and non-cleft (n = 39) individuals from three countries were included in this study. Two speech and language pathologists, blinded to the examination, rated the audio recording independently. Patients from Germany (n = 12; mean age 15.2), Iran (n = 14; mean age 7), and India (n = 15; mean age 14.7 years) were evaluated. We observed a significant difference in each category (p < 0.05) between patients and control subjects of the same language and cultural background. Hypernasality was affected the most. The test proved to possess the correct phonetic characteristics to reveal and provoke relevant cleft speech pathologies independent of cultural and language backgrounds. The test sounds posed no articulatory difficulties to non-cleft individuals, with some exceptions regarding non-specific consonant errors. A comparison with other existing tests will further illuminate its value as a speech test.

Speech, language, and reading skills in 10-year-old children with palatal clefts: The impact of additional conditions

BACKGROUND

This study examined speech (hypernasality and intelligibility), language, and reading skills in children with a cleft palate, specifically investigating additional conditions to the cleft, in order to differentiate challenges related to a cleft only, and challenges associated with an additional condition.

DESIGN

Cross-sectional data collected during routine assessments of speech and language in a centralised treatment setting.

PARTICIPANTS

Children born with cleft with palatal involvement from four birth cohorts (n=184), aged 10.

OUTCOME MEASURES

Speech: SVANTE-N; Language: Language 6-16; Reading: Word Chain Test and Reading Comprehension Test.

RESULTS

Descriptive analyses revealed that 123 of the children had a cleft only (66.8%), while 61 children (33.2%) had a cleft that was associated with an additional condition (syndrome, developmental difficulty, attentional difficulties). Due to close associations with the outcome variables, children with specific language impairments and dyslexia were excluded from the sample (n=14). In the total cleft sample, 33.1% had mild to severe hypernasality, and 27.9% had mild to severe intelligibility deviances. Most children with intelligibility and hypernasality scores within the normal range had a cleft without any other condition. A high number of children with developmental difficulties (63.2%) or AD/HD (45.5%) had problems with intelligibility. Hypernasality scores were also associated with developmental difficulties (58.8%), whereas most children with AD/HD had normal hypernasality scores (83.3%). As could be expected, results demonstrated that children with a cleft and an additional condition had language and reading scores below average. Children with a cleft only had language and reading scores within the normal range. Among the children with scores below average, 33.3-44.7% had no other conditions explaining difficulties with language and reading.

CONCLUSIONS

The findings highlight the need for routine assessments of language and reading skills, in addition to assessments of speech, in children with a cleft, in order to identify potential problems as early as possible. Study designs need to take additional difficulties into account, so that potential problems with language and reading are not ascribed the cleft diagnosis, and can be followed by appropriate treatment and interventions.

Isolated cleft palate requires different surgical protocols depending on cleft type

A staged protocol for isolated cleft palate (CPO), comprising the early repair of the soft palate at 6 months and delayed repair of the eventual cleft in the hard palate until 4 years, designed to improve maxillary growth, was introduced. CPO is frequently associated with additional congenital conditions. The study evaluates this surgical protocol for clefts in the soft palate (CPS) and for clefts in the hard and soft palate (CPH), with or without additional malformation, regarding primary and secondary surgical interventions needed for cleft closure and for correction of velopharyngeal insufficiency until 10 years of age. Of 94 consecutive children with CPO, divided into four groups with (+) or without (-) additional malformations (CPS + or CPS - and CPH + or CPH-), hard palate repair was required in 53%, performed with small local flaps in 21% and with bilateral mucoperiosteal flaps in 32%. The total incidence of soft palate re-repair was 2% and the fistula repair of the hard palate was 5%. The total incidence of secondary velopharyngeal surgery was 17% until 10 years, varying from 0% for CPS - and 15% for CPH-, to 28% for CPS + and 30% for CPH+. The described staged protocol for repair of CPO is found to be safe in terms of perioperative surgical results, with comparatively low need for secondary interventions. Furthermore, the study indicates that the presence of a cleft in the hard palate and/or additional conditions have a negative impact on the development of the velopharyngeal function.

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.

Influência da amostra de fala na classificação perceptiva da hipernasalidade

RESUMO Objetivo Investigar a influência do tipo de amostra de fala, conversa espontânea ou repetição de sentenças, sobre o índice de concordância intra e interavaliadores obtido na classificação perceptiva da hipernasalidade. Métodos Foram selecionadas e editadas 120 amostras de fala gravadas em áudio (60 contendo trechos de conversa espontânea e 60 contendo repetição de sentenças) de indivíduos com fissura de palato±lábio reparada, de ambos os sexos, com idade entre 6 e 52 anos (média=21±10 anos). Três fonoaudiólogas experientes, utilizando seus critérios internos, classificaram a hipernasalidade em escala de 4 pontos: 1=ausente, 2=leve, 3=moderada e 4=grave, primeiramente na amostra de conversa espontânea e, 30 dias depois, na repetição de sentenças. Os índices de concordância intra e interavaliadores foram estabelecidos para ambos os tipos de amostra de fala e comparados entre si por meio do Teste Z com nível de significância de 5%. Resultados A comparação dos índices de concordância intra-avaliadores entre os dois tipos de amostra de fala mostrou aumento dos coeficientes obtidos na análise da repetição de sentenças em relação aos obtidos na conversa espontânea, já a comparação entre os índices de concordância interavaliadores não mostrou diferença significante entre as três avaliadoras para os dois tipos de amostras de fala. Conclusão A repetição de sentenças favoreceu a confiabilidade do julgamento perceptivo da hipernasalidade de um mesmo avaliador, visto que a concordância intra-avaliadores na análise desta amostra de fala foi maior. No entanto, o tipo de amostra de fala não influenciou a concordância entre diferentes avaliadores.

Nasalância na presença e ausência da fricativa faríngea

RESUMO Objetivo: comparar os valores de nasalância em amostras de fala com e sem o uso de fricativa faríngea e, também, com e sem hipernasalidade. Métodos: um total de 840 amostras de fala foi analisado neste estudo. As amostras foram julgadas por três juízas experientes por consenso quanto aos aspectos hipernasalidade e fricativa faríngea. Os julgamentos foram distribuídos em quatro grupos: G1: 255 amostras de fala julgadas como representativas de hipernasalidade; G2: 130 amostras julgadas como representativas do uso de fricativa faríngea e hipernasalidade; G3: 280 amostras julgadas como representativas de fala normal em falantes com história de fissura labiopalatina; G4: 175 amostras julgadas como representativas de fala normal em falantes sem história de fissura labiopalatina. Para análise dos dados foi utilizando o teste Kruskal-Wallis e quando houve diferença estatisticamente significante foi aplicado o teste Dunn's para comparar os grupos aos pares. Resultados: os julgamentos aferidos por consenso pelas três juízas permitiram a identificação de amostras representativas do uso de fricativa faríngea e da presença e ausência de hipernasalidade. Foram estabelecidos valores de nasalância (média e desvio padrão) para cada grupo e observou-se que houve diferença estatisticamente significante entre os grupos com alteração de fala (G1 e G2) e aqueles sem alteração (G3 e G4). A diferença entre o grupo com hipernasalidade (G1) e o grupo com FF (G2) não foi significante. Conclusão: o uso de FF não influenciou significantemente os valores de nasalância para a amostra estudada.

Influência do treinamento dos avaliadores no julgamento perceptivo da hipernasalidade

RESUMO Introdução Alto índice de concordância no julgamento perceptivo da hipernasalidade entre diferentes avaliadores é difícil de ser alcançado. O treinamento prévio dos avaliadores e a padronização dos critérios de análise podem ser estratégias eficazes para minimizar o efeito da subjetividade do julgamento perceptivo e aumentar a concordância entre os avaliadores. Objetivo Investigar a influência do treinamento prévio sobre a concordância entre diferentes avaliadores no julgamento perceptivo da hipernasalidade. Métodos Três fonoaudiólogas experientes analisaram 77 amostras de fala, de indivíduos com fissura de palato reparada. Na primeira etapa, as avaliadoras classificaram a hipernasalidade utilizando seus próprios critérios, em uma escala de quatro pontos. Setenta dias depois, foram submetidas a um treinamento para a definição das amostras utilizadas como referências para o julgamento na etapa seguinte. Na segunda etapa as avaliadoras julgaram as mesmas amostras e classificaram a hipernasalidade com a mesma escala, utilizando como critério as referências definidas no treinamento. Índices de concordância intra e interavaliadores foram estabelecidos nas duas etapas utilizando-se o coeficiente Kappa e foram comparados por meio do teste Z. Resultados Os índices de concordância intra-avaliadores obtidos entre as duas etapas variou de 0,38 para 0,92, com diferença estatisticamente significativa para uma das avaliadoras (p=0,004). O índice de concordância quanto ao grau de hipernasalidade obtido entre as três avaliadoras após o treinamento (0,54) foi significativamente maior do que o obtido antes do treinamento (0,37; p=0,044). Conclusão O treinamento das avaliadoras e a definição de critérios para a classificação da hipernasalidade levam ao aumento do índice de concordância intra e interavaliadores.

Multiple phonetically trained-listener comparisons of speech before and after articulatory intervention in two children with repaired submucous cleft palate

Cleft Palate (CP) assessments based on phonetic transcription are the "gold standard" therapy outcome measure, despite reliability difficulties. Here we propose a novel perceptual evaluation, applied to ultrasound-visual biofeedback (U-VBF) therapy and therapy using visual articulatory models (VAMs) for two children with repaired submucous CP. Three comparisons were made: post VAM, post U-VBF and overall pre- and post-therapy. Twenty-two phonetically-trained listeners were asked to determine whether pre- or post-therapy recordings sounded "closer to the English target", using their own implicit phonological knowledge (prompted via orthographic representation). Results are compared with segment-oriented percent target consonant correct (PTCC) derived from phonetic transcriptions. Listener judgements and PTCC suggest that both children made improvements using both VAM and U-VBF. Statistical analysis showed listener agreement in each comparison, though agreement was weak. However, perceptual evaluation offers a straightforward method of evaluating the effectiveness of interventions and can be used by phonetically trained or lay listeners.

The Americleft Speech Project: A Training and Reliability Study

OBJECTIVE

To describe the results of two reliability studies and to assess the effect of training on interrater reliability scores.

DESIGN

The first study (1) examined interrater and intrarater reliability scores (weighted and unweighted kappas) and (2) compared interrater reliability scores before and after training on the use of the Cleft Audit Protocol for Speech-Augmented (CAPS-A) with British English-speaking children. The second study examined interrater and intrarater reliability on a modified version of the CAPS-A (CAPS-A Americleft Modification) with American and Canadian English-speaking children. Finally, comparisons were made between the interrater and intrarater reliability scores obtained for Study 1 and Study 2.

PARTICIPANTS

The participants were speech-language pathologists from the Americleft Speech Project.

RESULTS

In Study 1, interrater reliability scores improved for 6 of the 13 parameters following training on the CAPS-A protocol. Comparison of the reliability results for the two studies indicated lower scores for Study 2 compared with Study 1. However, this appeared to be an artifact of the kappa statistic that occurred due to insufficient variability in the reliability samples for Study 2. When percent agreement scores were also calculated, the ratings appeared similar across Study 1 and Study 2.

CONCLUSION

The findings of this study suggested that improvements in interrater reliability could be obtained following a program of systematic training. However, improvements were not uniform across all parameters. Acceptable levels of reliability were achieved for those parameters most important for evaluation of velopharyngeal function.

Julgamento perceptivo-auditivo das oclusivas velares associadas à fissura labiopalatina por juízes com e sem experiência

RESUMO: Objetivo: verificar: a) o grau de concordância de juízes no julgamento perceptivo-auditivo da produção de oclusivas velares, antes e depois da fonoterapia; b) a possível influência da composição fonética das amostras de fala nesta concordância e c) se os julgamentos obtidos por juízes com experiência diferem daqueles obtidos por juízes sem experiência, nas condições investigadas. Métodos: 60 amostras de fala de uma criança com fissura labiopalatina (30 previamente e 30 posteriormente a fonoterapia) e 30 amostras de fala de uma criança com fala típica (normal) foram julgadas por um grupo de 9 juízes. Três fonoaudiólogos estabeleceram os julgamentos consensuais "padrão ouro" para o estudo. Seis outros juízes julgaram as amostras: três considerados com experiência (fonoaudiólogos) e três sem experiência (alunos de graduação). As amostras de fala incluíram palavras constituídas pelas oclusivas velares /k/ e /g/ combinada com as vogais /a/, /i/ e /u/. Os juízes foram instruídos a julgar a presença, a ausência das oclusivas velares ou a presença de AC nestas amostras. Resultados: verificou-se diferenças no grau de concordância de juízes com experiência (Kappa moderada) e sem experiência (Kappa baixo) para os julgamentos realizados na condição pré-fonoterapia. O contexto fonético das amostras de fala influenciaram os julgamentos nas condições pré e pós-fonoterapia. Houve maior percentual de acerto para os juízes experientes condição pré-fonoterapia (p-valor <0,001). Conclusão: a experiência dos juízes e composição fonética das amostras de fala influenciam os julgamentos perceptivo-auditivos das AC.

The Cleft Care UK study. Part 4: perceptual speech outcomes

OBJECTIVES

To describe the perceptual speech outcomes from the Cleft Care UK (CCUK) study and compare them to the 1998 Clinical Standards Advisory Group (CSAG) audit.

SETTING AND SAMPLE POPULATION

A cross-sectional study of 248 children born with complete unilateral cleft lip and palate, between 1 April 2005 and 31 March 2007 who underwent speech assessment.

MATERIALS AND METHODS

Centre-based specialist speech and language therapists (SLT) took speech audio-video recordings according to nationally agreed guidelines. Two independent listeners undertook the perceptual analysis using the CAPS-A Audit tool. Intra- and inter-rater reliability were tested.

RESULTS

For each speech parameter of intelligibility/distinctiveness, hypernasality, palatal/palatalization, backed to velar/uvular, glottal, weak and nasalized consonants, and nasal realizations, there was strong evidence that speech outcomes were better in the CCUK children compared to CSAG children. The parameters which did not show improvement were nasal emission, nasal turbulence, hyponasality and lateral/lateralization.

CONCLUSION

These results suggest that centralization of cleft care into high volume centres has resulted in improvements in UK speech outcomes in five-year-olds with unilateral cleft lip and palate. This may be associated with the development of a specialized workforce. Nevertheless, there still remains a group of children with significant difficulties at school entry.

Avaliação da nasalidade de fala na fissura labiopalatina

Objetivo Descrever os resultados da nasalidade de fala de indivíduos com fissura labiopalatina e comparar os achados de nasalidade estabelecidos por meio do julgamento perceptivo-auditivo realizado ao vivo com os achados estabelecidos por análise de gravações por juízes, em dois tipos de amostras de fala. Métodos O estudo envolveu a análise retrospectiva dos resultados de avaliações perceptivo-auditivas da nasalidade de fala realizadas ao vivo por uma fonoaudióloga e o julgamento prospectivo, por consenso de juízas de 100 gravações de amostras de fala, obtidas durante a produção de dois conjuntos de estímulos de fala: um com consoantes de alta pressão (CAP, n=100) e outro com consoantes de baixa pressão (CBP, n=100). Os dados pertenciam a pacientes de ambos os gêneros, com idades entre 5 e 12 anos, que tiveram a fissura labiopalatina operada por um mesmo cirurgião. Resultados A ausência de hipernasalidade foi constatada em 69% dos julgamentos ao vivo. Quando presente, a hipernasalidade leve foi constatada em 23% dos casos, enquanto a hipernasalidade moderada em 8%. Para os julgamentos das amostras gravadas, 50% foram identificadas com hipernasalidade durante a produção das amostras CAP e 62% durante a das amostras CBP. Diferença significativa foi encontrada entre o resultado do julgamento ao vivo e o julgamento pelas juízas nas amostras CAP. A concordância entre as modalidades de avaliação variou de 79% para as amostras CAP e 80% para as amostras CBP, sendo considerada moderada. Conclusão O julgamento perceptivo ao vivo da nasalidade de fala pode detectar melhor a ausência de hipernasalidade, seguida pela hipernasalidade de grau leve, em comparação com o julgamento realizado por juízes múltiplos, a partir de amostras gravadas. Contudo, tem a desvantagem de os dados não poderem ser reproduzidos, nem quantificados, nem compartilhados por outros membros da equipe.

Speech outcomes at age 5 and 10 years in unilateral cleft lip and palate after one-stage palatal repair with minimal incision technique - a longitudinal perspective

OBJECTIVES

To investigate speech outcomes in 5- and 10-year-old children with unilateral cleft lip and palate (UCLP) treated according to minimal incision technique (MIT) - a one-stage palatal method.

METHODS

A retrospective, longitudinal cohort study of a consecutive series of 69 patients born with UCLP, treated with MIT (mean age 13 months) was included. Forty-two children (43%) received a velopharyngeal flap; 12 before 5 years and another 18 before 10 years of age. Cleft speech variables were rated from standardized audio recordings at 5 and 10 years of age, independently by three experienced, external speech-language pathologists, blinded to the material. The prevalences of cleft speech characteristics were determined, and inter- and intra-rater agreement calculated.

RESULTS

More than mild hypernasality, weak pressure consonants and perceived incompetent velopharyngeal function were present in 19-22% of the children at 5 years, but improved to less than 5% at 10 years. However, audible nasal air leakage, prevalent in 23% at 5 years, did not improve by age 10. Thirty percent had frequent or almost always persistent compensatory articulation at 5 years, and 6% at age 10. The general impression of speech improved markedly, from 57% giving a normal impression at 5 years to 89% at 10 years. A high prevalence of distorted/s/was found at both 5 and 10 years of age.

CONCLUSIONS

A high occurrence of speech deviances at 5 years of age after MIT was markedly reduced at 10 years in this study of children with unilateral cleft lip and palate. The high pharyngeal flap rate presumably accounted for the positive speech development.