Influence of Timing of Hard Palate Repair in a Two-Stage Procedure on Early Speech Development in Danish Children with Cleft Palate

Evidence-Based Practices in Cleft Palate Surgery

LEARNING OBJECTIVES

After studying this article, the participant should be able to: (1) Understand the embryologic origins, cause, and incidence of cleft palate. (2) Review the anatomy and common classifications of cleft palate and associated defects. (3) Describe surgical techniques for palatoplasty and understand their respective indications. (4) Gain an awareness of general perioperative care considerations, timing of repair, and risk factors for and operative mitigation of complications.

SUMMARY

Cleft palate affects 0.1 to 1.1 per 1000 births, with a higher incidence in certain ethnic groups but affecting both sexes equally. Cleft palate may occur in isolation or in combination with cleft lip or in association with other congenital anomalies including various syndromes. The goals of cleft palate repair are to anatomically separate the oral and nasal cavities for normal feeding and improved speech and minimize the risk of oronasal fistulas, velopharyngeal dysfunction, and disruption of facial growth. This review discusses the incidence, causes, and classification of cleft palate; surgical techniques for palatoplasty and perioperative patient management; and complications of palatoplasty.

Feasibility of using ultrasound visual biofeedback to treat persistent speech sound disorders in children with cleft palate- a case series

The current study aimed to assess the effectiveness of incorporating ultrasound visual biofeedback (UVB) into a treatment programme addressing persistent speech sound disorders linked to cleft palate in children who have been unresponsive to traditional therapy approaches. Materials and Methods. A single-subject multiple baseline experiment was conducted with five children aged 6:5-13:5 over a period of 16 therapy sessions. Treatment focused on providing cues from real-time ultrasound images to assist children in modifying their tongue movements. Probe data were collected before, mid, and post-treatment to assess target consonant accuracy for 50 untreated words. The results of the statistical analysis suggested participants showed a significant increase in percent target consonant accuracy as a result of intervention using UVB. Although most of the participants exhibited progress in generalising learned phonemes to untreated words, some did not show improvement in gaining generalisation from treated phonemic contexts to those untreated ones. When traditional methods fail to yield significant progress, incorporating ultrasound biofeedback into the treatment programme emerges as a viable option to enhance sound accuracy in children with persistent speech sound disorders resulting from cleft 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 Follow-up of Bilateral Cleft Lip and Palate: Incidence of Speech-Correcting Surgeries and Fistula Formation

While bilateral cleft lip and palate (BCLP) constitutes a clinical challenge for the whole cleft team, the ideal surgical protocol remains obscure. This study presents the long-term burden of care in terms of secondary surgeries, defined as fistula repair and speech-correcting surgeries (SCS), in a single center. Outcomes of two surgical protocols utilized over the years were also compared.

A retrospective single-center analysis of 81 non-syndromic children with complete BCLP born between 1990 and 2010. Two surgical protocols comprising single-stage and two-stage (delayed hard palate closure) procedures were compared. Outcome was analyzed at the time of alveolar bone grafting (ABG) and post-ABG.

Altogether 54 children (66.7%) had underwent secondary surgery by the time of bilateral ABG. At this point, 38.3% (n = 31) of patients had received SCS and 49.4% (n = 40) had undergone fistula repair. The corresponding incidences at the end of follow-up were 46.9% (n = 38) and 53.1% (n = 43). No significant difference emerged in SCS incidence between the 2 protocols; however, prior to ABG the single-stage protocol had a significantly lower need for fistula repair. Regarding the location of fistulas, some differences were observed, with the single-stage procedure more associated with anterior fistulas.

BCLP has a high surgical burden of care in terms of secondary surgeries, defined as SCS and fistula repair. In our experience, the single-stage protocol, particularly the two-flap technique, offers better results in the management of BCLP than the two-stage approach with a short delay in hard palate closure.

Six-year Burden of Care for Nonsyndromic Unilateral Cleft Lip and Palate Patients: A Comparison Between Cleft Centers and Noncleft Centers

OBJECTIVE

To determine differences in burden of care between nonsyndromic patients with unilateral cleft lip and palate undergoing treatment at American Cleft Palate-Craniofacial Association (ACPA)-accredited centers and nonaccredited centers in New York State.

DESIGN

A retrospective review of the New York Statewide Planning and Research Cooperative System database from January 2001 to December 2014 was performed using ICD-9 and CPT coding.

PATIENTS, PARTICIPANTS

This study included patients with unilateral cleft lip and palate who underwent both lip and palate repairs during their first  6 years of life. Exclusion criteria included orofacial cleft syndromes, follow-up under  6 years, and one-stage combined cleft lip and palate repairs.

RESULTS

Eighty-eight patients were treated at cleft centers, and 29 patients at nonaccredited centers (  n = 117). Age at primary palatoplasty (13.0 months vs 18.1 months;   p = .019), total number of cleft operations (2.3 vs 2.7;   p = .012), and total number of primary cleft-specific procedures (2.2 vs 2.5;   p = .0049) were significantly lower for patients treated in cleft centers. Age at primary cheiloplasty (4.8 months vs 4.6 months;   p = .865), post-cheiloplasty length of stay (1.2 days vs 1.2 days;   p = .673), post-palatoplasty length of stay (1.5 days vs 1.9 days;   p = .211), average hospital admissions (2.2 vs 2.3; p = 0.161), and total complication rates (34.1% vs 21.1%; p = 0.517) did not differ significantly between cleft centers and noncenters.

CONCLUSIONS

This data demonstrates some significant differences in overall 6 year burden of care for nonsyndromic patients with unilateral cleft lip and palate treated at ACPA-accredited cleft centers versus nonaccredited centers.

Risk of Malocclusion Among Patients Undergoing Single-Stage Versus Two-Stage Cleft Palate Repair

OBJECTIVE

Evaluate impact of single-stage versus staged palate repair on the risk of developing malocclusion among patients with cleft palate (CP).

DESIGN

Retrospective cohort study 2000-2016.

SETTING

Academic, tertiary children's hospital.

PATIENTS

Patients undergoing CP repair between 1999-2015.

INTERVENTIONS

CP repair, categorized as either single-stage or staged.

MAIN OUTCOME MEASURE

Time to development of Class III malocclusion.

RESULTS

967 patients were included; 60.1% had a two-stage CP repair, and 39.9% had single-stage. Malocclusion was diagnosed in 28.2% of patients. In the model examining all patients at ≤5 years (n = 659), patients who were not white had a higher risk of malocclusion (HR 2.46, p = 0.004) and staged repair was not protective against malocclusion (HR 0.98, p = 0.91). In all patients >5 years (n = 411), higher Veau classification and more recent year of birth were significantly associated with higher hazard rates (p < 0.05). Two-staged repair was not protective against developing malocclusion (HR 0.86, p = 0.60). In the model examining patients with staged repair ≤5 years old (n = 414), higher age at hard palate closure was associated with reduced malocclusion risk (HR 0.67, p < 0.001) and patients who were not white had increased risk (HR 2.56, p = 0.01). In patients with staged repair >5 years old, more recent birth year may be associated with a higher risk of malocclusion (HR 1.06, p = 0.06) while syndrome may be associated with lower risk of malocclusion diagnosis (HR 0.46, p = 0.07).

CONCLUSION

Our data suggests that staged CP repair is not protective against developing Class III malocclusion.

Phonological Profile of Patients With Velopharyngeal Dysfunction and Palatal Anomalies

PURPOSE

This purpose of this study was to assess the frequency and types of phonological process errors in patients with velopharyngeal dysfunction (VPD) and the different types of palatal anomalies.

METHOD

A total of 808 nonsyndromic patients with VPD, who underwent follow-up at the Center for Cleft Palate and Craniofacial Anomalies, from 2000 to 2016 were included. Patients were stratified into four age groups and five subphenotypes of palatal anomalies: cleft lip and palate (CLP), cleft palate (CP), submucous cleft palate (SMCP), occult submucous cleft palate (OSMCP), and non-CP. Phonological processes were compared among groups.

RESULTS

The 808 patients ranged in age from 3 to 29 years, and 439 (54.3%) were male. Overall, 262/808 patients (32.4%) had phonological process errors; 80 (59.7%) ages 3-4 years, 98 (40, 0%) ages 4.1-6 years, 48 (24.7%) 6.1-9 years, and 36 (15.3%) 9.1-29 years. Devoicing was the most prevalent phonological process error, found in 97 patients (12%), followed by cluster reduction in 82 (10.1%), fronting in 66 (8.2%), stopping in 45 (5.6%), final consonant deletion in 43 (5.3%), backing in 30 (3.7%), and syllable deletion and onset deletion in 13 (1.6%) patients. No differences were found in devoicing errors between palatal anomalies, even with increasing age. Phonological processes were found in 61/138 (44.20%) with CP, 46/118 (38.1%) with SMCP, 61/188 (32.4%) with non-CP, 70/268 (26.1%) with OSMCP, and 25/96 (26.2%) with CLP. Phonological process errors were most frequent with CP and least with OSMCP (p = .001).

CONCLUSIONS

Phonological process errors in nonsyndromic VPD patients remained relatively high in all age groups up to adulthood, regardless of the type of palatal anomaly. Our findings regarding the phonological skills of patients with palatal anomalies can help clarify the etiology of speech and sound disorders in VPD patients, and contribute to general phonetic and phonological studies.

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

OBJECTIVE

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

DESIGN

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

MAIN OUTCOME MEASURE(S)

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

RESULTS

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

CONCLUSIONS

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

Anesthetic Exposure in Staged Versus Single-Stage Cleft Lip and Palate Repair: Can We Reduce Risk of Anesthesia-Induced Developmental Neurotoxicity?

ABSTRACT

Cleft lip and palate (CLP) repair is typically performed in a staged fashion, which requires multiple instances of anesthetic exposure during a critical period of infant neurodevelopment. One solution to this concern includes the implementation of a single-stage CLP repair performed between 6 and 12 months of age. This study aimed to compare total anesthetic exposure between single-stage and staged CLP repairs. A retrospective review of unilateral CLP repairs between 2013 and 2018 conducted at a single institution was performed. Patients underwent either traditional, staged lip and palate repair, or single-stage complete cleft repair, where palate, lip, alveolus, and nasal repair was performed simultaneously. Primary endpoints included: total surgical time and total anesthetic exposure. Secondary endpoints included: excess anesthesia time, recovery room time, length of stay, and type of anesthetic administered. Two hundred twenty-five (n = 225) unilateral CLP repairs were conducted at the Loma Linda University. Detailed anesthetic data for eighty-six (n = 86) single-stage and twenty-eight (n = 28) staged operations were available. There was a statistically significant decrease in anesthetic exposure in single-stage versus staged repairs (316 minutes versus 345 minutes, P = 0.017), despite similar procedure times (260 minutes versus 246 minutes, P = 0.224). This resulted in near double excess anesthetic exposure time in the staged group (98 minutes versus 56 minutes, P < 0.001), primarily occurring during induction. This analysis suggests that single-stage CLP repair can reduce wasted time under general anesthesia and potentially reduce harmful neuronal toxicity in the developmental period in this at-risk population.

Speech and Audiology Outcomes After Single-Stage Versus Early 2-Stage Cleft Palate Repair

PURPOSE

The timing and management of patients with cleft palates have been controversial. Early soft palate closure at the time of cleft lip repair followed by hard palate closure at a second stage has been hypothesized to improve speech and audiology outcomes. This study compares cleft palate patients who have undergone single-stage versus 2-stage cleft palate repairs and the outcomes on speech and hearing.

METHODS

A retrospective chart review identified patients with diagnosis of cleft lip with complete cleft palate who underwent either single or 2-stage repair from 2006 to 2012. Data collected included age at each surgery, necessity of further speech surgery for velopharyngeal insufficiency, frequency of tympanostomy tube placement, presence of hearing loss, and speech assessment data graded per the validated Americleft speech scale.

RESULTS

A total of 84 patients were identified and subdivided into groups of single-stage and 2-stage repair. The mean age at the time of single-stage palate repair was 13.3 months. For the 2-stage group, the mean ages were 4.2 and 11.8 months for the soft palate and hard palate repairs, respectively. Comparing the single-stage versus 2-stage palate repairs, there was no significant difference in all speech parameters including hypernasality, hyponasality, nasal air emission, articulation, expressive language, receptive language, speech intelligibility, and speech acceptability for both unilateral and bilateral cleft lip/palate patients. Two-stage repair was associated with increased number of tympanostomy tube placement compared with single-stage repair (relative risk, 1.74; P = 0.009), and the first set of tubes was performed at a statistically significantly younger age, 4.5 months in the 2-stage repair compared with 16.9 months in the single-stage (P = 0.012) with 87.5% performed with first stage of repair. However, there was no difference in the types, degrees of hearing loss, or the presence of at least mild conductive hearing loss at latest follow-up audiograms between the groups.

CONCLUSIONS

There was no significant benefit with respect to speech or hearing outcomes between single-stage and 2-stage cleft palate repairs. This advocates for surgeon and family preference in the timing of cleft palate repair.

Ecuadorian Spanish translation and validation of the VELO quality of life instrument

OBJECTIVES

Adapt the Spanish translation of VPI Effects on Life Outcome (VELO) instrument into Ecuadorian Spanish; test the resulting instrument for reliability and validity.

METHODS

A cross-sectional, prospective design, set at a humanitarian mission within a community hospital. Linguistic validation: native Ecuadorian-Spanish speakers modified the Spanish VELO to Ecuadorian Spanish. Cognitive interviews were conducted with children with cleft palate (CP) and their parents (n = 50), guiding instrument modifications. An expert panel reviewed changes, resulting in the VELO-Ecuadorian dialect (VELO-Ec).

INSTRUMENT ASSESSMENT

88 participants with CP (88 parents, 46 children) and 33 non-cleft controls (33 adult, 11 children) completed the VELO-Ec, Spanish-Pediatric Voice Handicap Index (pVHI), and Spanish-Intelligibility in Context Scale (ICS). Internal consistency was assessed with Cronbach's alpha; test-retest reliability was assessed by calculating the intraclass correlation coefficient (ICC); standard error of measurement (SEM) was calculated. Concurrent validity was assessed with Pearson correlations of VELO-Ec with pVHI and ICS. Discriminant validity assessment used an established ICS cutoff. Construct validity was assessed by grouping patients by parent report of hypernasality and early vs. late cleft repair (>24 months) using the Wilcoxon Rank-Sum test.

RESULTS

VELO-Ec showed excellent internal consistency (alpha 0.96) and test-retest reliability (ICC = 0.85, 95% CI 0.68-0.93, SEM 5.71). It had strong concurrent validity, correlating with ICS (r = 0.75, p < 0.001) and pVHI (r = -0.79, p < 0.001). Discriminant validity was strong with better VELO-Ec scores among subjects with normal vs. abnormal ICS score (median 95 & 61, p < 0.001). Strong construct validity was identified: those with parent-reported hypernasality had worse VELO-Ec scores than those without (median 59 & 75, p < 0.001). Those with repair before or after 24 months had similar VELO-Ec scores (p = 0.882).

CONCLUSION

The VELO-Ec is a valid and reliable measure of VPI-related quality of life, useful to clinicians and researchers treating Ecuadorian CP patients, especially in areas with limited resources such as on humanitarian missions.

Speech of Patients With Unilateral Complete Cleft Lip and Palate: Comparison of Three Different Surgical Protocols for Primary Repair

BACKGROUND AND AIMS

Between 1997 and 2014, 3 protocols have been used in out cleft unit for primary repair of unilateral cleft lip and palate. During the Scandcleft randomized controlled trial closing the soft palate and lip at 4 months and the hard palate at 12 months (Protocol 1) was compared with closing the entire palate at 12 months (Protocol 2). Protocol 3 comprises closure of the lip and hard palate with a vomer flap at 4 months and the soft palate at 10 months. The purpose of this study was to compare subsequent velopharyngeal competence at age of 3 and 5 years.

PATIENTS AND METHODS

The study consisted of 160 non-syndromatic patients with a unilateral cleft lip and palate. Protocol 3 was retrospectively compared with Protocols 1 and 2 within the previously published Scandcleft study.

RESULTS

At 3 years of age, normal or borderline competent velopharyngeal function was found in 68% of patients in Protocol 1, 74% of patients in Protocol 2, and 72% of patients in Protocol 3. At 5 years of age, the corresponding figures were 84%, 82%, and 92%. 21% of patients in Protocol 1, 4% in Protocol 2, and 23% in Protocol 3 had palatal reoperations before the age of 5 years.

CONCLUSION

No significant differences emerged in velopharyngeal competence at age 3 years between the 3 protocols. Palatal reoperations were performed earlier in patient groups 1 and 3, explaining the difference in the velopharyngeal competence rate at the 5-year time-point.

Lessons from American Board of Plastic Surgery Maintenance of Certification Tracer Data: A 16-Year Review of Clinical Practice Patterns and Evidence-Based Medicine in Cleft Palate Repair

BACKGROUND

As a component of the Maintenance of Certification process from 2003 to 2019, the American Board of Plastic Surgery tracked 20 common plastic surgery operations. By evaluating the data collected over 16 years, the authors are able to examine the practice patterns of pediatric/craniofacial surgeons in the United States.

METHODS

Cumulative tracer data for cleft palate repair was reviewed as of April of 2014 and September of 2019. Evidence-based medicine articles were reviewed. Results were tabulated in three categories: pearls, or topics that were covered in both the tracer data and evidence-based medicine articles; topics that were covered by evidence-based medicine articles but not collected in the tracer data; and topics that were covered in tracer data but not addressed in evidence-based medicine articles.

RESULTS

Two thousand eight hundred fifty cases had been entered as of September of 2019. With respect to pearls, pushback, von Langenbeck, and Furlow repairs all declined in use, whereas intravelar veloplasty increased. For items not in the tracer, the quality of studies relating to analgesia is among the highest of all areas of study regarding cleft palate repair. In terms of variables collected by the tracer but not studied, in 2019, 41 percent of patients received more than 1 day of antibiotics.

CONCLUSIONS

This article provides a review of cleft palate tracer data and summarizes the research in the field. Review of the tracer data enables cleft surgeons to compare their outcomes to national norms and provides an opportunity for them to consider modifications that may enhance their practice.

Assessment of prelinguistic vocalizations in real time: a comparison with phonetic transcription and assessment of inter-coder-reliability

This study investigated reliability of naturalistic listening in real time (NLRT) compared to phonetic transcription. Speech pathology students with brief training in NLRT assessed prelinguistic syllable inventory size and specific syllable types in typically developing infants. A second study also examined inter-coder reliability for canonical babbling, canonical babbling ratio and presence of oral stops in syllable inventory of infants with cleft palate, by means of NLRT. In study 1, ten students independently assessed prelinguistic samples of five 12-month-old typically developing infants using NLRT and phonetic transcription. Coders assessed syllable inventory size as more than twice as large using phonetic transcription as NLRT. Results showed a strong correlation between NLRT and phonetic transcription (syllables with more than five occurrences) for syllable inventory size (r = .60; p < .001). The methods showed similar results for inter-coder reliability of specific syllable types. In study 2, three other students assessed prelinguistic samples of twenty-eight 12-month-old infants with cleft palate by means of NLRT. Results revealed perfect inter-coder agreement for presence/absence of canonical babbling, strong correlations between the three coders' assessment of syllable inventory size (average r = .83; p < .001), but more inter-coder variability for agreement of specific syllable types. In conclusion, NLRT is a reliable method for assessing prelinguistic measures in infants with and without cleft palate with inter-coder agreement levels comparable to phonetic transcription for specific syllable types.

Lexical Selectivity of 2-Year-Old Children With and Without Repaired Cleft Palate Based on Parent Report

OBJECTIVE

To determine vocabulary and lexical selectivity characteristics of children with and without repaired cleft palate at 24 months of age, based on parent report.

PARTICIPANTS

Forty-nine children with repaired cleft palate, with or without cleft lip (CP±L; 25 males; 21 cleft lip and palate, 28 CP only), 29 children with a history of otitis media (OM) and ventilation tubes (21 males), and 25 typically developing (TD) children (13 males).

MAIN OUTCOME MEASURE(S)

Parent-reported expressive vocabulary was determined using the MacArthur Communicative Development Inventory: Words and Sentences.

RESULTS

Vocabulary size was reduced for children with repaired CP±L compared to children in the TD group (P = .025) but not the OM group (P = .403). Mean percentage of words beginning with sonorants did not differ across groups (P = .383). Vocabulary size predicted sonorant use for all groups (P = .001).

CONCLUSIONS

Children with repaired CP±L exhibit similar lexical selectivity relative to word initial sounds compared to noncleft TD and OM peers at 24 months of age, based on parent report.

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.

Cost Utility Analysis of Staged Versus Single-Stage Cleft Lip and Palate Repair

PURPOSE

As one of the most common congenital craniofacial deformities, cleft lip and palate repair is a complex and much published topic. Proper treatment can require a multitude of appointments and operations and can place a significant burden on both the patients' families and the health care system itself. One proposed solution has been to combine multiple cleft procedures. However, these more complex operations have drawn concerns from institutions and providers regarding increased cost. This study provides a cost utility analysis between single-stage and staged unilateral cleft lip and palate repairs.

METHODS

A retrospective review was conducted via current procedural terminology code identification of all cleft-related operations performed between 2013 and 2018. Patients were screened according to diagnosis, and only analysis on unilateral cleft lip and palate patients was performed. Patients were split into 2 cohorts: those that underwent a single-stage complete cleft repair, which includes palate, lip, alveolus, and nasal repair-termed "PLAN" at our institution, and those that underwent more traditional staged lip and palate repairs. Demographic and billing data were collected for any procedure performed between patient ages 0 and 24 months. χ, t-tests, and parametric regression analyses were performed to compare the cohorts.

RESULTS

Between 2013 and 2018, 968 (n = 968) cleft-related operations were conducted at Loma Linda University Children's Hospital. Seven hundred ninety-six (n = 796) noncleft lip/palate repairs and 38 (n = 38) bilateral cleft lip repairs were excluded. Of the remaining 135 (n = 135) patients with unilateral cleft lip and palate, detailed cost data were available for 86 single-stage and 28 staged repairs. The average combined total cost for single-stage repairs was US $80,405 compared with US $109,473 for staged repairs (P < 0.001). The average total intraoperative cost for single-stage repairs was US $60,683 versus US $79,739 for staged repairs (P < 0.001), and the average total postoperative cost for single-stage repairs versus staged repairs was US $19,776 and US $29,703, respectively (P < 0.001).

CONCLUSIONS

This analysis suggests that single-stage PLAN repair, provides an effective, cost-efficient solution to unilateral cleft lip and palate care, reducing burden on patients' families and the health care system at large.

Scandcleft randomized trials of primary surgery for unilateral cleft lip and palate. Dental arch relationships in 8 year-olds

BACKGROUND AND TRIAL DESIGN

The Scandcleft intercentre study evaluates the outcomes of four surgical protocols for treatment of children with unilateral cleft lip and palate (UCLP). Originally 10 cleft centres in Denmark, Finland, Norway, Sweden, and the UK participated in a set of three randomized trials of primary surgery. Three groups of centres (Trials 1, 2, and 3) tested their traditional local surgical protocols (Arms B, C, and D) against a common protocol (Arm A).

OBJECTIVES

To evaluate dental arch relationships at age 8 years after four different protocols of primary surgery for UCLP. These results are secondary outcomes of the overall trial.

METHODS

Study models of 411 children (270 boys, 141 girls) with non-syndromic UCLP at a mean age of 8.1 (range 7.0-10.0) years were available. Dental arch relationships were analysed using the GOSLON Yardstick by a blinded panel of 11 orthodontists. To assess reliability, Kappa statistics were calculated. The trials were tested statistically with t-tests.

RESULTS

Comparisons within each trial showed no statistically significant differences in the mean 8-year index scores or their distributions between the common protocol and the local team protocol. The mean index scores were Trial 1: Arm A 3.03, Arm B 2.82, Trial 2: Arm A 2.78, Arm C 2.64, and Trial 3: Arm A 3.06, Arm D 3.08. Comparisons between the trials detected a significantly (P < 0.005) better mean index score Trial 2 Arm C than in Trial 3 Arm D. The intra- and inter-rater reliabilities were acceptable.

CONCLUSION

The results of these three trials do not provide evidence that one surgical protocol is better than the others.

TRIAL REGISTRATION

ISRCTN29932826.

Longitudinal study of the development of obstruent correctness from ages 3 to 5 years in 108 Danish children with unilateral cleft lip and palate: a sub-study within a multicentre randomized controlled trial

BACKGROUND

Speech-sound development in preschoolers with unilateral cleft lip and palate (UCLP) as a group is delayed/disordered, and obstruents comprise the most vulnerable sound class.

AIMS

To evaluate the development of obstruent correctness (PCC-obs) and error types (cleft speech characteristics (CSCs) and developmental speech characteristics (DSCs)) from ages 3-5 and to investigate possible predictors (error types, velopharyngeal dysfunction (VPD) and gender) of PCC-obs at age 5 in two groups of children with UCLP.

METHODS & PROCEDURES

Subgroup analysis was conducted within a multicentre randomized controlled trial (RCT) of primary surgery (Scandcleft Project). A total of 125 Danish children with UCLP received lip and soft palate repair around 4 months of age and early hard palate closure at 12 months (EHPC group) or late hard palate closure at 36 months (LHPC group). Audio and video recordings of a naming test were available for 108 children at ages 3 and 5, and recordings were transcribed phonetically by blinded raters.

OUTCOMES & RESULTS

PCC-obs scores increased significantly from ages 3-5 in both groups, but with small effect sizes in the EHPC group that had higher scores at age 3 than the LHPC group. DSCs decreased in both groups whereas CSCs only decreased in the LHPC group that had more CSCs at age 3 than the EHPC group. The frequency of CSCs at age 3 was a significant predictor of PCC-obs scores at age 5 in both groups. DSCs significantly improved the logistic regression model in the EHPC group, whereas VPD and gender did not significantly improve the model in either group.

CONCLUSIONS & IMPLICATIONS

Although PCC-obs developed significantly from ages 3 to 5, children with UCLP as a group did not catch up to typically developing Danish children at age 5. Furthermore, the LHPC group at age 5 did not reach the 3-year level of the EHPC group, which means that delaying hard palate closure until age 3 is detrimental to obstruent development. Both CSCs and DSCs at age 3 were important predictors of PCC-obs at age 5 and should be considered when determining need for intervention.

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.

Scandcleft Project, Trial 1: Comparison of Speech Outcome in Relation to Timing of Hard Palate Closure in 5-Year-Olds With UCLP

OBJECTIVE

To compare in-depth speech results in Scandcleft Trial 1 as well as reference data from peers without cleft palate (CP).

DESIGN

A prospective randomized clinical trial.

SETTING

A Danish and a Swedish CP center.

PARTICIPANTS

143 of 148 randomized 5-year-olds with unilateral cleft lip and palate. All received lip and velum closure at 4 months, and hard palate closure at 12 months (arm A) or 36 months (arm B).

MAIN OUTCOME MEASURES

A composite measure based on velopharyngeal competence (VPC) or velopharyngeal incompetence (VPI), an overall assessment of VPC from connected speech (VPC-Rate), Percentage of Consonants Correct (PCC-score), and consonant errors. Speech therapy visits, average hearing thresholds, and secondary pharyngeal surgeries documented burden of treatment.

RESULTS

Across the trial, 61.5% demonstrated VPC and 38.5% VPI. Twenty-two percent of participants achieved age appropriate PCC-scores. There were no statistically significant differences between arms or centers for these measures. In the Danish center, arm B: achieved lower PCC-scores (P = .01); obtained PCC-scores without s-errors below 79% (P = .002); produced ≥3 active oral cleft speech characteristics (P = .004) than arm A. In both centers, arm B attended more speech visits.

CONCLUSIONS

At age 5, differences between centers and treatment arms were not statistically significant for VPC/VPI, but consonant proficiency differed between treatment arms in the Danish center. Poor speech outcomes were seen for both treatment arms. Variations between centers were observed. As the Swedish center had few participants, intercenter comparisons should be interpreted with caution.

Determining postoperative outcomes after cleft palate repair: A systematic review and meta-analysis

BACKGROUND

A lack of high-level evidence exists on the outcomes of different cleft palate repair techniques. A critical appreciation for the complication rates of common repair techniques is paramount to optimize cleft palate care.

METHODS

A literature search was conducted for articles on the measurement of fistula and velopharyngeal insufficiency (VPI) rates following cleft palate repair. Study quality was determined using validated scales. The heterogeneity between studies was evaluated using the I² statistic. Random-effect model analysis and forest plots were used to report pooled relative risks (RRs) with 95% confidence intervals for treatment effect. P-values of 0.05 were considered statistically significant.

RESULTS

Of 2386 studies retrieved, 852 underwent screening and 227 met inclusion criteria (130 studies (57%) on fistulas and 122 studies (54%) on VPI). Meta-analyses were performed using 32 studies. The Furlow technique was associated with less postoperative fistulae than the von Langenbeck and Veau/Wardill/Kilner techniques (RR = 0.56 [0.39-0.79], p < 0.01 and RR = 0.25 [0.12-0.52], p < 0.01, respectively). One-stage repair was associated with less fistulae compared to two-stage repair (RR = 0.42 [0.19-0.96], p = 0.04). The Furlow repair was also associated with a less VPI than the Bardach palatoplasty (RR = 0.41 [0.23, 0.71], p < 0.01), and the one-stage repair was associated with a reduction in VPI rates compared to two-stage repair (RR = 0.55 [0.32, 0.95], p = 0.03).

CONCLUSION

The Furlow repair is associated with less risk of fistula formation than the von Langenbeck and Veau/Wardill/Kilner techniques and less VPI compared to the Bardach repair. One-stage repair is associated with less risk of fistula formation and VPI than two-stage repair.

A Review of Randomized Controlled Trials in Cleft and Craniofacial Surgery

This study presents a systematic review of randomized controlled trials (RCTs) in cleft and craniofacial surgery. All studies reporting on RCTs in cleft and craniofacial surgery were identified on PubMed using the search terms "cleft," "velopharyngeal insufficiency," "velopharyngeal dysfunction," "nasoalveolar molding," "gingivoperiosteoplasty," "Pierre Robin sequence," "craniofacial," "craniosynostosis," "craniofacial microsomia," "hemifacial microsomia," "hypertelorism," "Le Fort," "monobloc," "distraction osteogenesis," "Treacher Collins," and "Goldenhar." Studies were excluded if they were not randomized, did not focus primarily on topics related to cleft or craniofacial surgery, included repeat publications of data, or were unavailable in English. Studies were evaluated on demographic and bibliometric data, study size, specific area of focus, and findings reported. Four hundred forty-seven unique studies were identified. One hundred eighty-three papers met inclusion criteria (115 cleft lip and palate, 65 craniofacial, and 3 spanning both disciplines). Sixty-six (36%) were dedicated to topics related to surgical techniques. There were no studies comparing current cleft lip or soft palate repair techniques and no studies on cleft rhinoplasty. The most frequently reported surgical topic was cleft palate. There were several studies on orthognathic techniques which compared distraction osteogenesis to traditional advancement. Most craniofacial operations, such as cranial vault remodeling and frontofacial advancement/distraction, were not represented. Several standard operations in cleft and craniofacial surgery are not supported by Level I evidence from randomized controlled trials. Our community should consider methods by which more RCTs can be performed, or redefine the acceptable standards of evidence to guide our clinical decisions.

Longitudinal Comparison of the Speech and Language Performance of United States-Born and Internationally Adopted Toddlers with Cleft Lip and Palate

Objective:

This study compares the early speech and language development of children with cleft palate with or without cleft lip who were adopted internationally with children born in the United States.

Design:

Prospective longitudinal description of early speech and language development between 18 and 36 months of age.

Participants:

This study compares four children (age range = 19 to 38 months) with cleft palate with or without cleft lip who were adopted internationally with four children (age range = 19 to 38 months) with cleft palate with or without cleft lip who were born in the United States, matched for age, gender, and cleft type across three time points over 10 to 12 months.

Main Outcome Measures:

Children's speech-language skills were analyzed using standardized tests, parent surveys, language samples, and single-word phonological assessments to determine differences between the groups.

Results:

The mean scores for the children in the internationally adopted group were lower than the group born in the United States at all three time points for expressive language and speech sound production measures. Examination of matched pairs demonstrated observable differences for two of the four pairs. No differences were observed in cognitive performance and receptive language measures.

Conclusions:

The results suggest a cumulative effect of later palate repair and/or a variety of health and environmental factors associated with their early circumstances that persist to age 3 years. Early intervention to address the trajectory of speech and language is warranted. Given the findings from this small pilot study, a larger study of the long-term speech and language development of children who are internationally adopted and have cleft palate with or without cleft lip is recommended.

Influence of timing of delayed hard palate closure on articulation skills in 3-year-old Danish children with unilateral cleft lip and palate

BACKGROUND

Differing results regarding articulation skills in young children with cleft palate (CP) have been reported and often interpreted as a consequence of different surgical protocols.

AIMS

To assess the influence of different timing of hard palate closure in a two-stage procedure on articulation skills in 3-year-olds born with unilateral cleft lip and palate (UCLP). Secondary aims were to compare results with peers without CP, and to investigate if there are gender differences in articulation skills. Furthermore, burden of treatment was to be estimated in terms of secondary surgery, hearing and speech therapy.

METHODS & PROCEDURES

A randomized controlled trial (RCT). Early hard palate closure (EHPC) at 12 months versus late hard palate closure (LHPC) at 36 months in a two-stage procedure was tested in a cohort of 126 Danish-speaking children born with non-syndromic UCLP. All participants had the lip and soft palate closed around 4 months of age. Audio and video recordings of a naming test were available from 113 children (32 girls and 81 boys) and were transcribed phonetically. Recordings were obtained prior to hard palate closure in the LHPC group. The main outcome measures were percentage consonants correct adjusted (PCC-A) and consonant errors from blinded assessments. Results from 36 Danish-speaking children without CP obtained previously by Willadsen in 2012 were used for comparison.

OUTCOMES & RESULTS

Children with EHPC produced significantly more target consonants correctly (83%) than children with LHPC (48%; p < .001). In addition, children with LHPC produced significantly more active cleft speech characteristics than children with EHPC (p < .001). Boys achieved significantly lower PCC-A scores than girls (p = .04) and produced significantly more consonant errors than girls (p = .02). No significant differences were found between groups regarding burden of treatment. The control group performed significantly better than the EHPC and LHPC groups on all compared variables.

Scandcleft randomised trials of primary surgery for unilateral cleft lip and palate: 5. Speech outcomes in 5-year-olds - consonant proficiency and errors

BACKGROUND AND AIM

Normal articulation before school start is a main objective in cleft palate treatment. The aim was to investigate if differences exist in consonant proficiency at age 5 years between children with unilateral cleft lip and palate (UCLP) randomised to different surgical protocols 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, Norway, Sweden, 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 non-syndromic UCLP. Speech audio- and video-recordings of 391 children (136 girls and 255 boys) were available and transcribed phonetically. The main outcome measure was Percent Consonants Correct (PCC) from blinded assessments.

RESULTS

In Trial 1, arm A showed statistically significant higher PCC scores (82%) than arm B (78%) (p = .045). No significant differences were found between prevalences in Trial 2, A: 79%, C: 82%; or Trial 3, A: 80%, D: 85%. Across all trials, girls achieved better PCC scores, excluding s-errors, than boys (91.0% and 87.5%, respectively) (p = .01).

CONCLUSIONS

PCC scores were higher in arm A than B in Trial 1, whereas no differences were found between arms in Trials 2 or 3. The burden of care in terms of secondary pharyngeal surgeries, number of fistulae, and speech therapy visits differed.

TRIAL REGISTRATION

ISRCTN29932826.

Speech in Adults Treated for Unilateral Cleft Lip and Palate: Long-Term Follow-Up after One- or Two-Stage Palate Repair

Objective

To evaluate speech in adults treated for unilateral cleft lip and palate with one-stage or two-stage palate closure and compare the speech of the patients with that of a noncleft control group.

Design

Cross-sectional study with long-term follow-up.

Participants/Setting

All unilateral cleft lip and palate patients born from 1960 to 1987 and treated at Uppsala University Hospital, Sweden, were invited (n = 109). Participation rate was 67% (n = 73) at a mean of 35 years after primary surgery. Forty-seven had been treated according to one-stage palate closure and 26 according to two-stage palate closure. Pharyngeal flap surgery had been performed in 11 of the 73 patients (15%). The noncleft control group consisted of 63 age-matched volunteers.

Main Outcome Measure(s)

Speech-language pathologists rated perceptual speech characteristics from blinded audio recordings.

Results

Among patients, seven (10%) presented with hypernasality, 12 (16%) had audible nasal emission and/or nasal turbulence, five (7%) had consonant production errors, one (2%) had glottal reinforcements/substitutions, and one (2%) had reduced intelligibility. Controls had no audible signs of velopharyngeal insufficiency and no quantifiable problems with the other speech production variables. No significant differences were identified between patients treated with one-stage and two-stage palate closure for any of the variables.

Conclusions

The prevalence of speech outcome indicative of velopharyngeal insufficiency among adult patients treated for unilateral cleft lip and palate was low but higher compared with individuals without cleft. Whether palatal closure is performed in one or two stages does not seem to affect the speech outcome at a mean age of 35 years.

Speech outcome in young children born with unilateral cleft lip and palate treated with one- or two-stage palatal repair and the impact of early intervention

OBJECTIVES

The aim of this study was to describe speech at 1, 1;6 and 3 years of age in children born with unilateral cleft lip and palate (UCLP) and relate the findings to operation method and amount of early intervention received.

METHODS

A prospective trial of children born with UCLP operated with a one-stage (OS) palatal repair at 12 months or a two-stage repair (TS) with soft palate closure at 3-4 months and hard palate closure at 12 months was undertaken (Scandcleft). At 1 and 1;6 years the place and manner of articulation and number of different consonants produced in babbling were reported in 33 children. At three years of age percentage consonants correct adjusted for age (PCC-A) and cleft speech errors were assessed in 26 of the 33 children. Early intervention was not provided as part of the trial but according to the clinical routine and was extracted from patient records.

RESULTS

At age 3, the mean PCC-A was 68% and 46% of the children produced articulation errors with no significant difference between the two groups. At one year there was a significantly higher occurrence of oral stops and anterior place consonants in the TS group. There were significant correlations between the consonant production between one and three years of age, but not with amount of early intervention received.

CONCLUSIONS

The TS method was beneficial for consonant production at age 1, but not shown at 1;6 or 3 years. Behaviourally based early intervention still needs to be evaluated.

Speech production in 3-year-old internationally adopted children with unilateral cleft lip and palate

BACKGROUND

In the last decade, a large number of children with cleft lip and palate have been adopted to Sweden. A majority of the children were born in China and they usually arrive in Sweden with an unoperated palate. There is currently a lack of knowledge regarding speech and articulation development in this group of children, who also have to deal with a late first language switch.

AIMS

To study consonant proficiency in 3-year-old internationally adopted children with unilateral cleft lip and palate (UCLP) compared with peers with UCLP born in Sweden. Also to study the type and frequency of consonant errors and to perceptually compare velopharyngeal competence between the groups.

METHODS & PROCEDURES

Thirty-two children born between 2006 and 2010 with UCLP participated in the study-14 adopted from China and 18 children born in Sweden. Both groups were treated by the same cleft palate team. Audio recordings at 3 years of age were perceptually analysed by blinded listeners. Consonant proficiency was measured via per cent consonants correct adjusted for age (PCC-A), per cent correct manners (PCM) and per cent correct places (PCP). The prevalence of audible nasal air leakage and velopharyngeal competence were judged and compared between groups. The type and frequencies of consonant errors related to place and manner of articulation were also analysed.

OUTCOMES & RESULTS

The internationally adopted children had significantly fewer correct consonants compared with the Swedish-born children. This was true for PCC-A, PCP and PCM. This group also had significantly higher prevalence of glottal stops/fricatives and deleted target consonants more often. Also the internationally adopted children had a higher prevalence of incompetent velopharyngeal function. The only outcome variable with similar results in the groups was audible nasal air leakage.

CONCLUSIONS & IMPLICATIONS

The present study indicated that there were significant differences regarding consonant proficiency and velopharyngeal competence between internationally adopted children with a UCLP and their Swedish-born peers with UCLP at the age of 3 years. Internationally adopted children with UCLP should be considered an at risk group for a higher prevalence of speech difficulties than non-adoptees. Thus, it is particularly important to follow this group of children over time. Longitudinal studies of speech and language development in internationally adopted children with UCLP are needed.

Does the recording medium influence phonetic transcription of cleft palate speech?

BACKGROUND

In recent years, analyses of cleft palate speech based on phonetic transcriptions have become common. However, the results vary considerably among different studies. It cannot be excluded that differences in assessment methodology, including the recording medium, influence the results.

AIMS

To compare phonetic transcriptions from audio and audio/video recordings of cleft palate speech by means of outcomes of per cent correct consonants (PCC) and differences in consonant transcriptions.

METHODS & PROCEDURES

Thirty-two 3-year-olds born with cleft palate were audio and audio/video recorded while performing a single-word test by picture naming. The recordings were transcribed according to the International Phonetic Alphabet. The transcriptions from the audio and the audio/video recordings were analysed with regard to PCC, differences in the use of phonetic consonant symbols and the use of diacritics.

OUTCOMES & RESULTS

PCC was higher when the calculation was based on transcriptions from audio recordings than when based on audio/video recordings. No such differences were seen when age-appropriate consonant processes were scored as correct. Consonants were not excluded as often in the transcriptions from audio/video recordings as they were in the transcriptions from audio recordings, and more target consonants were transcribed as dental/alveolar in the transcriptions from audio/video recordings and palatal/velar/uvular in the transcriptions from audio recordings than vice versa. Further, interdental articulation, linguolabial articulation and audible nasal air leakage were more common in the transcriptions from audio/video recordings than in those from audio recordings. All these differences were statistically significant.

CONCLUSIONS & IMPLICATIONS

Phonetic transcription is influenced to some extent by visual cues. However, as long as age-appropriate articulatory and phonological simplification processes are scored as correct when evaluating consonant production in the speech of young children born with cleft palate using phonetic transcription, the recording medium does not seem to affect the results.

Profiles of vocal development in Korean children with and without cleft palate

This study longitudinally investigated vocal development in Korean children from 9 to 18 months of age with and without cleft palate (CP). Utterance samples were collected from 24 children with and without CP at 9, 12, 15 and 18 months of age. Each utterance was categorised into levels of vocalisation using the Korean-translated version of the Stark Assessment of Early Vocal Development-Revised (SAEVD-R). The results showed children with CP produced a significantly higher rate of precanonical vocalisations (the combination of Levels 1, 2, and 3) and a lower rate of Level 4 and 5 vocalisations than children without CP. Both groups showed decreases in Levels 1 and 2 and increases in Level 5 from 9 to 18 months of age. A significant increase in the proportion of Level 4 vocalisations across age was observed only in children without CP. Young Korean children with CP showed lower proportions of advanced vocalisation levels characterised by canonical and complex syllable structures across 9 and 18 months of age compared to children without CP.

Relationship between Orthodontic Treatment Plan and Goslon Yardstick Assessment in Japanese Patients with Unilateral Cleft Lip and Palate: One-stage vs. Two-stage Palatoplasty

The present study targeted patients with unilateral cleft lip and palate (UCLP) undergoing either one - (Wardill technique) or two-stage palatoplasty (Perko technique). Correlations between Goslon Yardstick scores and orthodontic appliances used and whether an osteotomy was performed were investigated. No differences were observed between the two types of palatoplasty in terms of Goslon Yardstick scores. A palatal expander and protraction facemask were used in Phase I of orthodontic treatment. The palatal expander was selected for most patients with UCLP in Phase I, regardless of the surgical technique used. A protraction facemask was used in patients undergoing the Wardill procedure who had a Goslon Yardstick score placing them in Group 3 or 4. In contrast, a protraction facemask was used in patients undergoing the Perko procedure who had a Goslon Yardstick score placing them in Group 4. No significant differences were observed in the Goslon Yardstick scores yielded by either type of procedure. The Goslon Yardstick score in relation to whether an osteotomy was performed in Phase II as part of orthodontic treatment was determined, focusing on the relationship between that score and the palatoplasty method used. A protraction facemask was used in patients undergoing the Perko procedure, which eliminated the need for an osteotomy at a future date. However, a protraction facemask was also used in patients undergoing the Wardill option, and those patients were likely to require an osteotomy. In other words, the results suggest that the type of palatoplasty selected will determine the effectiveness of any orthodontic appliances used.

Phonology in Swedish-speaking 5-year-olds born with unilateral cleft lip and palate and the relationship with consonant production at 3 years of age

PURPOSE

At ∼3 years of age ∼50% of the children born with cleft palate present with phonological/articulatory difficulties. Differences between children with and without cleft palate have been reported to decline with age; however, the phonology in children with cleft palate at pre-school age/early school age has rarely been explored. The purpose of this study was to assess phonology in children with unilateral cleft lip and palate (UCLP) at age 5 and its relationship with performances at 3 years of age.

METHOD

The study included 29 children with UCLP and 20 without UCLP. Percentage correct consonants adjusted for age (PCC-A) and number of consistent phonological simplification processes were assessed from phonetic transcriptions. In addition, a descriptive analysis of phonological/articulatory processes was performed.

RESULT

The children with UCLP displayed significantly lower PCC-A and more phonological processes at age 5 years than peers without UCLP. The correlations between the outcomes at 3 and 5 years of age were significant.

CONCLUSION

Still at 5 years of age many children with cleft palate have phonological problems and it is possible to identify children at risk for impaired phonology at earlier age.

Verbal competence in narrative retelling in 5-year-olds with unilateral cleft lip and palate

BACKGROUND

Research regarding expressive language performance in children born with cleft palate is sparse. The relationship between articulation/phonology and expressive language skills also needs to be further explored.

AIMS

To investigate verbal competence in narrative retelling in 5-year-old children born with unilateral cleft lip and palate (UCLP) and its possible relationship with articulation/phonology at 3 and 5 years of age.

METHODS & PROCEDURES

A total of 49 children, 29 with UCLP treated according to three different procedures for primary palatal surgery and a comparison group of 20 children (COMP), were included. Longitudinally recorded audio files were used for analysis. At ages 3 and 5, the children were presented with a single-word test of word naming and at age 5 also the Bus Story Test (BST). The BST was assessed according to a test manual. The single-word test was phonetically transcribed and the percentage of consonants correct adjusted for age (PCC-A) was calculated. Differences regarding the BST results within the UCLP group were analysed. The results were compared with the results of the COMP group, and also with norm values. In addition, the relationship between the results of the BST and the PCC-A scores at ages 3 and 5 years was analysed.

OUTCOMES & RESULTS

No significant group differences or correlations were found. However, 65.5% of the children in the UCLP group had an information score below 1 standard deviation from the norm value compared with 30% in the COMP group.

CONCLUSIONS

A larger proportion of children in the UCLP group than in the COMP group displayed problems with retelling but the differences between the two groups were not significant. There was no association between the BST results in the children with UCLP and previous or present articulatory/phonological competence. Since group size was small in both groups, the findings need to be verified in a larger study.

Verification of the therapeutic process in cleft patients

PURPOSE: This study was conducted to verify the origin of a longer or even failed therapeutic process in patients with cleft lip and palate as to its difficulty. METHODS: Eighteen children undergoing therapeutic process were observed for at least 6 months and divided into two groups: presenting isolated cleft lip and palate (group I) and having been diagnosed by a Speech-Language Pathologist with reading and writing disorders, with manifestation of phonological awareness deficit (group II). Two tests were applied for the evaluation of speech and language: ABFW Language Test for Young Children (phonology) and Phonological Awareness: Instrument of Sequential Assessment (CONFIAS). RESULTS: Group I presented higher percentages in ABFW test than group II, except in the "simplification of consonant cluster" and "plosive devoicing" variables. It was also observed that, in the process of omission, group I hardly omits the vibrant consonant, as observed in group II. At the syllable level of CONFIAS, the percentages observed in group I tended to be higher than in group II, with the exception of the following tasks: "medial syllable," "production of rhyme," and "exclusion." At the phoneme level, the percentages observed in group II tended to be higher than in group I, with the exception of the following tasks: "starts with given sound," "exclusion," "synthesis," and "segmentation." No significant difference was observed between percentage distributions in groups I and II (p>0.118). CONCLUSIONS: The differences found between groups I and II, although not statistically significant, may suggest that the presence of malformation hinders speech and language acquisition and development and prolongs the therapeutic process if directive interventions are not carried out, including phonological awareness therapy.

Speech and Phonology in Swedish-Speaking 3-Year-Olds with Unilateral Complete Cleft Lip and Palate following Different Methods for Primary Palatal Surgery

Objective

To describe and compare speech and phonology at age 3 years in children born with unilateral complete cleft lip and palate treated with three different methods for primary palatal surgery.

Design

Prospective study.

Setting

Primary care university hospitals.

Participants

Twenty-eight Swedish-speaking children born with nonsyndromic unilateral complete cleft lip and palate.

Interventions

Three methods for primary palatal surgery: two-stage closure with soft palate closure between 3.4 and 6.4 months and hard palate closure at mean age 12.3 months (n = 9) or 36.2 months (n = 9) or one-stage closure at mean age 13.6 months (n = 10).

Main Outcome Measures

Based on independent judgments performed by two speech-language pathologists from standardized video recordings: percent correct consonants adjusted for age, percent active cleft speech characteristics, total number of phonological processes, number of different phonological processes, hypernasality, and audible nasal air leakage. The hard palate was unrepaired in nine of the children treated with two-stage closure.

Results

The group treated with one-stage closure showed significantly better results than the group with an unoperated hard palate regarding percent active cleft speech characteristics and total number of phonological processes.

Conclusions

Early primary palatal surgery in one or two stages did not result in any significant differences in speech production at age 3 years. However, children with an unoperated hard palate had significantly poorer speech and phonology than peers who had been treated with one-stage palatal closure at about 13 months of age.

Phonology in Swedish-speaking 3-year-olds born with cleft lip and palate and the relationship with consonant production at 18 months

BACKGROUND

Approximately 50% of children born with cleft palate present speech difficulties around 3 years of age, and several studies report on persisting phonological problems after palatal closure. However, studies on early phonology related to cleft palate are few and have so far mainly been carried out on English-speaking children. Studies on phonology related to cleft palate in languages other than English are also warranted.

AIMS

To assess phonology in Swedish-speaking children born with and without unilateral cleft lip and palate (UCLP) at 3 years of age, and to identify variables at 18 months that are associated with restricted phonology at age 3 years.

METHODS & PROCEDURES

Eighteen consecutive children born with UCLP and 20 children without cleft lip and palate were included. Transcriptions of audio recordings at 18 months and 3 years were used. Per cent correct consonants adjusted for age (PCC-A), the number of established phonemes, and phonological simplification processes at 3 years were assessed and compared with different aspects of consonant inventory at 18 months.

OUTCOMES & RESULTS

PCC-A, the number of established phonemes, and the total number of phonological processes differed significantly at 3 years between the two groups. Total number of oral consonants, oral stops, dental/alveolar oral stops and number of different oral stops at 18 months correlated significantly with PCC-A at 3 years in the UCLP group.

CONCLUSIONS & IMPLICATIONS

As a group, children born with UCLP displayed deviant phonology at 3 years compared with peers without cleft lip and palate. Measures of oral consonant and stop production at 18 months might be possible predictors for phonology at 3 years in children born with cleft palate.

Early hard palate closure using a vomer flap in unilateral cleft lip and palate: effects on cleft width

OBJECTIVES

Although no universal consensus exists on treatment of cleft palates, early hard palate closure is commonly performed. The aim of the present study was to determine the influence of a vomer flap for early hard palate closure on residual palatal cleft width in patients with a unilateral complete cleft lip and palate (UCLP).

MATERIALS AND METHODS

Forty-seven UCLP patients were retrospectively divided into two groups. Group A consisted of 25 patients who underwent early lip closure and simultaneous hard palate closure using a vomer flap. Group B included 22 patients who had lip closure only at first surgery. Palatal cleft widths of both groups were measured at two time points and were compared using the Mann-Whitney U test to examine the influence of vomerplasty in this very early stage.

RESULTS

No significant difference of baseline characteristics between the groups was found, and comparison of age at the time of surgeries was not significantly different. Mean age at the time of vomerplasty was 4.0 months. After the first surgery, a significantly greater total cleft width reduction of 5.0 mm average was found in group A compared to only 1.5 mm reduction in group B. This reduction took place after an average of 7.1 and 7.0 months, respectively.

CONCLUSIONS

Lip closure accompanied by early hard palate closure using a vomer flap is associated with a significant postoperative reduction of the residual cleft when compared to lip closure only.

CLINICAL RELEVANCE

This study shows another great advantage of performing early hard palate closure using a vomer flap.

Longitudinal comparison of early speech and language milestones in children with cleft palate: a comparison of US and Slovak children

The purpose of this study was to compare early speech and language development of children with and without cleft lip and/or palate (CLP) in the US and Slovakia from 6 to 24 months of age. Thirty-two children from the US (eight with CLP and eight noncleft) and Slovakia (eight with CLP and eight noncleft) participated in this study. The children were videotaped at four time points for 30 minutes during mother-child interaction with play sets controlled for early-developing sounds in each language. Mean Babbling Level, consonant inventories, number of different words and mean length of utterance were calculated for 6- to 24-month samples. Results indicated that the US and Slovak groups showed similar performance across the ages. Cleft and noncleft groups showed significant differences in acquisition of all of the speech and language measures. High-pressure consonants, particularly alveolar place of articulation, were problematic for children with CLP.

Speech outcomes of early palatal repair with or without intravelar veloplasty in children with complete unilateral cleft lip and palate

We compared the early speech outcomes of 40 consecutive children with complete unilateral cleft lip and palate (UCLP) who had been treated according to different 2-stage protocols: the Malek protocol (soft palate closure without intravelar veloplasty at 3 months; lip and hard palate repair at 6 months) (n=20), and the Talmant protocol (cheilorhinoplasty and soft palate repair with intravelar veloplasty at 6 months; hard palate closure at 18 months) (n=20). We compared the speech assessments obtained at a mean (SD) age of 3.3 (0.35) years after treatment by the same surgeon. The main outcome measures evaluated were acquisition and intelligibility of speech, velopharyngeal insufficiency, and incidence of complications. A delay in speech articulation of one year or more was seen more often in patients treated by the Malek protocol (11/20) than in those treated according to the Talmant protocol (3/20, p=0.019). Good intelligibility was noted in 15/20 in the Talmant group compared with 6/20 in the Malek group (p=0.010). Assessment with an aerophonoscope showed that nasal air emission was most pronounced in patients in the Malek group (p=0.007). Velopharyngeal insufficiency was present in 11/20 in the Malek group, and in 3/20 in the Talmant group (p=0.019). No patients in the Talmant group had an oronasal fistula (p<0.001). All other outcomes were similar. Despite later closure of the soft and hard palate, early speech outcomes were better in the Talmant group because intravelar veloplasty was successful and there were no fistulas after closure of the hard palate in 2 layers.