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

Comparing Methodologies in a Series of Speech Outcome Studies

Background:

Development of the speech audit tool Cleft Audit Protocol for Speech Augmented (CAPS-A) facilitated intercenter comparison of speech outcomes following cleft palate repair. The CAPS-A protocol recommends consensus listening by 3 speech and language therapists, 2 of whom must be CAPS-A trained. Allowing 15 minutes per sample, 15 to 20 samples can be assessed each day. Centers typically have resources to audit 15 to 75 samples per year but not to report speech outcomes of larger data sets for research. This 3-phased outcome study examines how the implementation of the CAPS-A protocol might be modified without compromising reliability.

Methodology:

In phase 1, 2 external listeners independently rated 42 speech samples; in phase 2, 2 external listeners consensus listened 25% of 140 samples before 1 listener independently rated the remainder; phase 3 compared 124 Great Ormond Street Speech Assessment (GOS.SP.ASS’98) records from live assessments with CAPS-A-rated video samples.

Results:

Hypernasality, nasal airflow, and passive cleft speech characteristics were rated to identify signs of velopharyngeal dysfunction across all phases. Phase 1 demonstrated suboptimal correlation, intraclass correlation coefficient (ICC) ranging between 0.39 and 0.72. However, the “modified” CAPS-A consensus listening process in phase 2 achieved a mean ICC of 0.91. Phase 3 revealed only moderate agreement between GOS.SP.ASS’98 and CAPS-A.

Conclusion:

A large data set of speech samples was successfully managed by establishing good interrater reliability on 25% of the data, which calibrated the listeners and validated a decision for only 1 of 2 listeners to rate the remaining speech samples. The recommended implementation of the CAPS-A protocol can therefore be modified for more efficient speech outcome reporting.

Association Between Facial Length and Width and Fundamental Frequency

OBJECTIVE

This study aimed to evaluate the association between facial width and length and fundamental frequency (F0) and habitual frequency.

STUDY DESIGN

Prospective cross-sectional study.

SUBJECTS

A total of 50 subjects (35 females;15 males) were included in this study.

METHODS

Lateral and posteroanterior cephalometric measurements included: facial height (N-Me); widths of the maxilla (J-J), mandible (AG-AG), and face (Zyg-Zyg); ratios J-J to AG-AG, N-Me to Zyg-Zyg, and lower face to total face heights. All subjects underwent acoustic analysis using Visi-Pitch IV. Sample was stratified according to age and gender.

RESULTS

In the total group (mean age: 14.19±6.49 years; range 6-35 years), a significantly moderate negative correlation existed between Zyg-Zyg, J-J, and AG-AG, and F0 and habitual pitch. Similarly, N-Me moderately correlated with habitual pitch. In males, there was a significant moderate negative correlation between Zyg-Zyg and J-J, and habitual pitch, and between J-J and F0 (-0.571;p=0.026). In females, a significant moderate correlation existed between Zyg-Zyg and AG-AG, and habitual pitch, and between AG-AG and F0 (-0.347;p=0.041). In the prepubertal group (n=25), a negative moderate correlation occurred between J-J and AG-AG, N-Me and habitual frequency, and between J-J and F0 (-0.407;p=0.043). In the postpubertal group, there was a significant moderate correlation only between AG-AG and F0 (-0.403;p=0.046).

CONCLUSION

Facial length correlates significantly with habitual frequency, and facial width correlates significantly with both F0 and habitual pitch. A larger sample of adult subjects is needed to substantiate this conclusion.

Dandy-Walker syndrome with severe velopharyngeal dysfunction: a contraindication for Le Fort I surgery?

Dandy-Walker syndrome is a rare congenital brain deformation. Most symptoms are related with fourth ventricle and skull base malformations. Quite often, symptoms develop from infancy or progress rapidly. Cerebellar dysfunction, lack of muscle coordination, and skull deformities involving eye movement might be present. There are several Dandy-Walker syndrome complex types. We present a 23-year-old patient who had a severe dentofacial deformity with mandibular prognathism and extremely undeveloped maxillary bone resulting in palatopharyngeal and velopharyngeal dysfunction with complete lack of soft palate function resulting in increased speech tone and volume. Performing Le Fort I osteotomy in this case is greatly controversial and might result in even greater loss of function or even its total lack. Velopharyngeal complex is very important, and every surgeon should consider its value while planning Le Fort I osteotomies.

Formants frequency and dispersion in relation to the length and projection of the upper and lower jaws

OBJECTIVE

Investigate the association between formants frequencies and length and sagittal projection of the maxilla and mandible.

STUDY DESIGN

Cross-sectional study.

METHOD

A total of 47 consecutive patients were recruited. Craniofacial measures included; maxillary length (ANS-PNS), mandibular length (Co-Gn), relationship between maxilla and mandible in the sagittal plane (ANB), the sagittal projection of the maxilla (SNA), and mandible (SNB). Subjects were asked to phonate vowels /a/, /i/, /o/, and /u/. Measurements were made in real-time and formant frequencies across F1, F2, F3, and F4 were determined.

RESULTS

There was a significant negative association between the length of the maxilla and F4 for all the vowels, and a significant negative association between the length of the mandible and F4 for vowels /o/ and /u/. The length of maxilla and mandible also negatively associated with F3 for vowels /a/, /i/, /o/, and vowels /i/, /o/, and /u/ respectively. For the first two formants, the negative association was less pronounced.

CONCLUSION

There was a significant negative association between the formant frequencies F3, F4, and the length of the mandible and maxilla for vowels /a/, /i/, /o/, and /u/.

The relation of nasality and nasalance to nasal port area based on a computational model

OBJECTIVE

The purpose of this study was to examine the relation of perceptual ratings of nasality by experienced listeners, measures of nasalance, and the size of the nasal port opening for three simulated English corner vowels, /i/, /u/, and /a/.

DESIGN

Samples were generated using a computational model that allowed for exact control of nasal port size and a direct measure of nasalance. Perceptual ratings were obtained using a paired-stimulus presentation.

PARTICIPANTS

Five experienced listeners.

MAIN OUTCOME MEASURES

Measures of nasalance and perceptual nasality ratings.

RESULTS

Differences in nasalance and perceptual ratings of nasality were noted among the three vowels, with values being greater for the high vowels /i/ and /u/ compared to the low vowel /a/. Listeners detected nasality for the high and low vowels simulated with nasal port areas of 0.01 and 0.15 cm(2), respectively. Correlations between ratings of nasality and nasalance were high for all three vowels.

CONCLUSIONS

Results of the present study show a high correlation between ratings of nasality and measures of nasalance for nasal port areas ranging from 0 to 0.5 cm(2). The correlations were based on sustained vowel samples. The restricted speech sample limits generalization of the findings to clinical data; however, the results are a demonstration of the usefulness of modeling to understand the perceptual phenomena of nasality.

Regenerate healing outcomes in unilateral mandibular distraction osteogenesis using quantitative histomorphometry

BACKGROUND

The authors' goal was to ascertain regenerate bone-healing metrics using quantitative histomorphometry at a single consolidation period.

METHODS

Rats underwent either mandibular distraction osteogenesis (n = 7) or partially reduced fractures (n = 7); their contralateral mandibles were used as controls (n = 11). External fixators were secured and unilateral osteotomies performed, followed by either mandibular distraction osteogenesis (4 days' latency, then 0.3 mm every 12 hours for 8 days; 5.1 mm) or partially reduced fractures (fixed immediately postoperatively; 2.1 mm); both groups underwent 4 weeks of consolidation. After tissue processing, bone volume/tissue volume ratio, osteoid volume/tissue volume ratio, and osteocyte count per high-power field were analyzed by means of quantitative histomorphometry.

RESULTS

Contralateral mandibles had statistically greater bone volume/tissue volume ratio and osteocyte count per high-power field compared with both mandibular distraction osteogenesis and partially reduced fractures by almost 50 percent, whereas osteoid volume/tissue volume ratio was statistically greater in both mandibular distraction osteogenesis specimens and partially reduced fractures compared with contralateral mandibles. No statistical difference in bone volume/tissue volume ratio, osteoid volume/tissue volume ratio, or osteocyte count per high-power field was found between mandibular distraction osteogenesis specimens and partially reduced fractures.

CONCLUSIONS

The authors' findings demonstrate significantly decreased bone quantity and maturity in mandibular distraction osteogenesis specimens and partially reduced fractures compared with contralateral mandibles using the clinically analogous protocols. If these results are extrapolated clinically, treatment strategies may require modification to ensure reliable, predictable, and improved outcomes.

Velopharyngeal insufficiency: diagnosis and management

PURPOSE OF REVIEW

Journal articles relevant to the diagnosis and treatment of velopharyngeal insufficiency were reviewed. All studies ascertained by PubMed search were included.

RECENT FINDINGS

Studies reported on the application of magnetic resonance scanning, reliability tests of the International Working Group diagnostic protocol, the use of nasometry, and techniques designed to assess the function of the velopharyngeal mechanism. Treatment studies focused on outcomes in small samples of cases and complication rates from pharyngeal flap. One study discussed ineffective speech therapy procedures.

SUMMARY

There were relatively few studies this past year. Those that were published were hindered by small and heterogeneous sample sizes and occasionally by inappropriate methods for assessing outcomes. None of the findings will have a major impact on the current state-of-the-art for diagnosis of velopharyngeal insufficiency. The speech therapy study has a very important message that should be taken to heart by all clinicians involved in the management of children with clefts and craniofacial disorders.