Analysis of Speech Characteristics in Children With Velocardiofacial Syndrome (VCFS) and Children With Phenotypic Overlap Without VCFS

Speech Sounds Production, Narrative Skills, and Verbal Memory of Children with 22q11.2 Microdeletion

22q11.2 deletion syndrome (22q11.2DS), the most frequent microdeletion syndrome in humans, is related to a high risk of developing neurodevelopmental disorders. About 95% of patients with 22q11.2DS have speech and language impairments. Global articulation, story generation, and verbal memory tests were applied to compare articulatory characteristics of speech sounds, spontaneous language abilities, and immediate verbal memory between four groups of Serbian-speaking children: patients with 22q11.2DS, children with clinical presentation of 22q11.2DS that do not have the microdeletion, children with non-syndromic congenital heart defects, and their peers with typical speech-sound development. The obtained results showed that children with this microdeletion have impaired articulation skills and expressive language abilities. However, we did not observe weaker receptive language skills and immediate verbal memory compared to healthy controls. Children with 22q11.2DS should be considered a risk category for the development of speech-sound pathology and expressive language abilities. Since speech intelligibility is an instrument of cognition and adequate peer socialization, and language impairment in school-aged children with 22q11DS might be an indicator of increased risk for later psychotic symptoms, patients with 22q11.2 microdeletion should be included in a program of early stimulation of speech-language development immediately after diagnosis is established.

Exploring a neurogenic basis of velopharyngeal dysfunction in Tbx1 mutant mice: no difference in volumes of the nucleus ambiguus

OBJECTIVE

Velopharyngeal hypotonia seems to be an important factor in velopharyngeal dysfunction in 22q11.2 deletion syndrome, but the etiology is not understood. Because TBX1 maps within the typical 22q11.2 deletion and Tbx1-deficient mice phenocopy many findings in patients with the 22q11.2 deletion syndrome, TBX1 is considered the major candidate gene in the etiology of these defects. Tbx1 heterozygosity in mice results in abnormal vocalization 7 days postnatally, suggestive of velopharyngeal dysfunction. Previous case-control studies on muscle specimens from patients and mice revealed no evidence for a myogenic cause of velopharyngeal dysfunction. Velopharyngeal muscles are innervated by cranial nerves that receive signals from the nucleus ambiguus in the brainstem. In this study, a possible neurogenic cause underlying velopharyngeal dysfunction in Tbx1 heterozygous mice was explored by determining the size of the nucleus ambiguus in Tbx1 heterozygous and wild type mice.

METHODS

The cranial motor nuclei in the brainstems of postnatal day 7 wild type (n=4) and Tbx1 heterozygous (n=4) mice were visualized by in situ hybridization on transverse sections to detect Islet-1 mRNA, a transcription factor known to be expressed in motor neurons. The volumes of the nucleus ambiguus were calculated.

RESULTS

No substantial histological differences were noted between the nucleus ambiguus of the two groups. Tbx1 mutant mice had mean nucleus ambiguus volumes of 4.6 million μm(3) (standard error of the mean 0.9 million μm(3)) and wild type mice had mean volumes of 3.4 million μm(3) (standard error of the mean 0.6 million μm(3)). Neither the difference nor the variance between the means were statistically significant (t-test p=0.30, Levene's test p=0.47, respectively).

CONCLUSIONS

Based on the histology, there is no difference or variability between the volumes of the nucleus ambiguus of Tbx1 heterozygous and wild type mice. The etiology of velopharyngeal hypotonia and variable speech in children with 22q11.2 deletion syndrome warrants further investigation.

Speech and hearing in adults with 22q11.2 deletion syndrome

The purpose of the study was to investigate the prevalence of velopharyngeal impairment, compensatory articulation, reduced intelligibility, and to rate the general impression of speech in adults with 22q11.2 deletion syndrome. The second purpose was to study the prevalence and type of hearing impairment in these adults. A referred, consecutive series of 24 adults with confirmed 22q11.2 deletion, 16 female and 8 males, with a mean age of 25 years (19-38 years) was included in the study. A blind assessment of speech by three experienced speech-language pathologists was performed. Sixteen (66%) patients had a mild to severe velopharyngeal impairment. The most prevalent symptoms of velopharygeal impairment were hypernasality and audible nasal airflow. The mean nasalance score was 33% (6-66%). Only two patients had disordered articulation; one of these had glottal articulation. A mean of 96% (88-100%) of single words were rated to be intelligible. To achieve these results half of the patients previously had velopharyngeal flap surgery. Forty-one percent (9/22) had mild-moderate hearing impairment; three had sensorineural type, four conductive and two had a mixed type. In conclusion the majority of the patients had no articulation errors and good intelligibility; while one-third still had moderate to severe problems with velopharyngeal impairment. Around 40% still had some hearing impairment, in most cases with a mild to moderate conductive component. Thus, a high prevalence of speech and hearing problems seems to be a part of the phenotype in adults with 22q11.2DS.

In search of the optimal surgical treatment for velopharyngeal dysfunction in 22q11.2 deletion syndrome: a systematic review

BACKGROUND

Patients with the 22q11.2 deletion syndrome (22qDS) and velopharyngeal dysfunction (VPD) tend to have residual VPD following surgery. This systematic review seeks to determine whether a particular surgical procedure results in superior speech outcome or less morbidity.

METHODOLOGY/ PRINCIPAL FINDINGS

A combined computerized and hand-search yielded 70 studies, of which 27 were deemed relevant for this review, reporting on a total of 525 patients with 22qDS and VPD undergoing surgery for VPD. All studies were levels 2c or 4 evidence. The methodological quality of these studies was assessed using criteria based on the Cochrane Collaboration's tool for assessing risk of bias. Heterogeneous groups of patients were reported on in the studies. The surgical procedure was often tailored to findings on preoperative imaging. Overall, 50% of patients attained normal resonance, 48% attained normal nasal emissions scores, and 83% had understandable speech postoperatively. However, 5% became hyponasal, 1% had obstructive sleep apnea (OSA), and 17% required further surgery. There were no significant differences in speech outcome between patients who underwent a fat injection, Furlow or intravelar veloplasty, pharyngeal flap pharyngoplasty, Honig pharyngoplasty, or sphincter pharyngoplasty or Hynes procedures. There was a trend that a lower percentage of patients attained normal resonance after a fat injection or palatoplasty than after the more obstructive pharyngoplasties (11-18% versus 44-62%, p = 0.08). Only patients who underwent pharyngeal flaps or sphincter pharyngoplasties incurred OSA, yet this was not statistically significantly more often than after other procedures (p = 0.25). More patients who underwent a palatoplasty needed further surgery than those who underwent a pharyngoplasty (50% versus 7-13%, p = 0.03).

CONCLUSIONS/ SIGNIFICANCE

In the heterogeneous group of patients with 22qDS and VPD, a grade C recommendation can be made to minimize the morbidity of further surgery by choosing to perform a pharyngoplasty directly instead of only a palatoplasty.

Speech outcomes and velopharyngeal function after surgical treatment of velopharyngeal insufficiency in individuals with signs of velocardiofacial syndrome

OBJECTIVE

The objective of the study was to analyze if individuals with velocardiofacial syndrome (VCFS) present the same characteristics of speech and velopharyngeal function (VPF) compared with patients with nonsyndromic submucous cleft palate, as well as to compare the effectiveness of palate surgery on the speech function and VPF between groups.

METHODS

This was a prospective study performed at the Speech Therapy Sector and Physiology Laboratory, Hospital for Rehabilitation of Craniofacial Anomalies/University of São Paulo.The procedure performed was primary palatoplasty associated or not to superiorly based pharyngeal flap surgery.There were 50 patients with velopharyngeal insufficiency: 25 with signals of VCFS (VCFS group) and 25 without syndrome with submucous cleft palate (SMCP group).The hypernasality was scored by 3 examiners; nasalance was evaluated by nasometry, and VPF was assessed by the size of the velopharyngeal gap on the nasoendoscopy. The evaluations were conducted before and, in average, 18 months after surgery.

RESULTS

Before surgery, the VCFS and SMCP groups presented similar speech function and VPF characteristics in all parameters, with no statistically significant differences. After surgery, there was reduction in the hypernasality, nasalance, and VPF in, respectively, 20%, 31%, and 36% of patients in the VCFS group and in 24%, 30%, and 30% in the SMCP group. Elimination/normalization of variables was obtained in 28%, 19%, and 8% of patients in the VCFS group and 20%, 40%, and 25% in the SMCP group, respectively, for hypernasality, nasalance, and VPF. There was no statistically significant difference between groups.

CONCLUSIONS

Patients with VCFS presented similar speech function and VPF characteristics as patients with nonsyndromic SMCP. The surgery for velopharyngeal insufficiency correction was equally effective for the improvement and resolution of speech symptoms and VPF in patients with VCFS compared with the SMCP group.

Histology of the pharyngeal constrictor muscle in 22q11.2 deletion syndrome and non-syndromic children with velopharyngeal insufficiency

Plastic surgeons aim to correct velopharyngeal insufficiency manifest by hypernasal speech with a velopharyngoplasty. The functional outcome has been reported to be worse in patients with 22q11.2 deletion syndrome than in patients without the syndrome. A possible explanation is the hypotonia that is often present as part of the syndrome. To confirm a myogenic component of the etiology of velopharyngeal insufficiency in children with 22q11.2 deletion syndrome, specimens of the pharyngeal constrictor muscle were taken from children with and without the syndrome. Histologic properties were compared between the groups. Specimens from the two groups did not differ regarding the presence of increased perimysial or endomysial space, fiber grouping by size or type, internalized nuclei, the percentage type I fibers, or the diameters of type I and type II fibers. In conclusion, a myogenic component of the etiology of velopharyngeal insufficiency in children with 22q11.2 deletion syndrome could not be confirmed.

Factors affecting articulation skills in children with velocardiofacial syndrome and children with cleft palate or velopharyngeal dysfunction: a preliminary report

OBJECTIVE

To examine the influence of speech perception, cognition, and implicit phonological learning on articulation skills of children with velocardiofacial syndrome (VCFS) and children with cleft palate or velopharyngeal dysfunction (VPD).

DESIGN

Cross-sectional group experimental design.

PARTICIPANTS

Eight children with VCFS and five children with nonsyndromic cleft palate or VPD.

METHODS AND MEASURES

All children participated in a phonetic inventory task, speech perception task, implicit priming nonword repetition task, conversational sample, nonverbal intelligence test, and hearing screening. Speech tasks were scored for percentage of phonemes correctly produced. Group differences and relations among measures were examined using nonparametric statistics.

RESULTS

Children in the VCFS group demonstrated significantly poorer articulation skills and lower standard scores of nonverbal intelligence compared with the children with cleft palate or VPD. There were no significant group differences in speech perception skills. For the implicit priming task, both groups of children were more accurate in producing primed nonwords than unprimed nonwords. Nonverbal intelligence and severity of velopharyngeal inadequacy for speech were correlated with articulation skills.

CONCLUSIONS

In this study, children with VCFS had poorer articulation skills compared with children with cleft palate or VPD. Articulation difficulties seen in the children with VCFS did not appear to be associated with speech perception skills or the ability to learn new phonological representations. Future research should continue to examine relationships between articulation, cognition, and velopharyngeal dysfunction in a larger sample of children with cleft palate and VCFS.

Compensatory articulations in a case of congenital aglossia

This paper examines the articulatory and phonatory strategies used by a German female born without a tongue. Analysis concentrates on the phonetic correlates of dorsal plosives. The speaker uses two main strategies. In word list material, closure for initial /k, g/ is produced using a combination of the uvula, floor of the mouth and adduction of the glossopalatal arches. In other environments, closure is made at the glottis. The glottal strategy is shown to be consistently different from the junctural glottalization used at vowel onset.

A multiple case study of verbal short-term memory in velo-cardio-facial syndrome

BACKGROUND

Velo-cardio-facial syndrome (VCFS, 22q11.2 deletion) is characterized by severely delayed language development. The current study explored the integrity of verbal short-term memory (STM), a cognitive function critically involved in language development, in eight children with VCFS.

METHODS

Using a multiple case study design, we presented a series of STM tasks exploring immediate serial recall for word and non-word lists to eight children with VCFS (aged 8-12 years) and to chronological-age-matched control groups. A first task assessed the integrity of phonological coding in verbal STM by comparing recall for phonologically similar and dissimilar words. Subsequently, the interaction between verbal knowledge and STM capacity was investigated by comparing recall for high- and low-imageability words, for high- and low-frequency words, and for words and non-words. A final task assessed short-term serial order recognition for digit sequences.

RESULTS

When computing the number of items recalled in the word recall tasks, independently of their serial position, only one child presented consistent difficulties. Short-term recall of non-words was normal in each child. Phonological similarity and verbal knowledge influenced STM performance to a similar extent in children with VCFS and controls. On the other hand, when applying a strict serial recall criterion, difficulties with the word and non-word recall tasks were observed in most children. Half of the patients were also impaired in the serial order recognition task.

CONCLUSIONS

Despite mild intellectual disability, it is possible for short-term retention capacities for verbal item information to be at an age-appropriate level in VCFS. However, STM for serial order information could be impaired more specifically.

COMT Val108/158 Met modifies mismatch negativity and cognitive function in 22q11 deletion syndrome

BACKGROUND

Microdeletions at 22q11.2 greatly increase the risk of schizophrenia in early adulthood (relative risk approximately 25-30). We hypothesized that before the onset of schizophrenia, individuals with 22q11DS would manifest specific cognitive and neurophysiological anomalies (endophenotypes) in common with individuals at high risk for schizophrenia in the general population. We further predicted that the catechol-O-methyltransferase Val(108/158)Met polymorphism, located within the deleted chromosomal segment, would modify the severity of endophenotypic features.

METHODS

22q11DS adolescents and young adults (aged 13-21) were compared with age- and IQ-matched control subjects on measures that are associated with risk of idiopathic schizophrenia.

RESULTS

22q11DS subjects displayed poorer verbal working memory and expressive language performance than control subjects. Auditory mismatch negativity (MMN) event-related potentials were reduced at frontal electrodes but were intact at temporal sites. Presence of the COMT(108/158)Met allele on the single intact chromosome 22 was associated with more marked MMN amplitude reduction and poorer neuropsychological performance. Neither COMT Val(108/158)Met allele influenced psychiatric symptoms.

CONCLUSIONS

22q11DS is associated with neurodevelopmental characteristics that are similar to idiopathic schizophrenia. The COMT Val(108/158)Met polymorphism modifies the severity of endophenotypes for schizophrenia, indicating that impaired catecholamine regulation contributes to neuropsychiatric risk in 22q11DS.

22q11.2 deletion syndrome: genetics, neuroanatomy and cognitive/behavioral features keywords

This paper presents a conceptual review of the genetic underpinnings of 22q11.2 Deletion Syndrome. The neuroanatomical, neuropsychological, behavioral, and psychiatric phenotype associated with 22q11.2 Deletion Syndrome is also explored, including variables that are thought to affect symptom expression. The history of the deletion syndrome is described, and future directions for continued research are discussed.

Annotation: velo-cardio-facial syndrome

BACKGROUND

Velo-cardio-facial syndrome (VCFS), the most frequent known interstitial deletion identified in man, is associated with chromosomal microdeletions in the q11 band of chromosome 22. Individuals with VCFS are reported to have a characteristic behavioural phenotype with high rates of behavioural, psychiatric, neuropsychological and linguistic disorders.

METHODS

A selective literature review was undertaken.

RESULTS

Children and adults with VCFS have high rates of behavioural, psychiatric and communication disorders. While VCFS children have high rates of ADHD, anxiety and affective disorders, adults have high rates of psychotic disorders, particularly schizophrenia. In addition, the presence of a chromosome 22q11 deletion is associated with specific neuropsychological and neuroanatomical abnormalities.

CONCLUSIONS

People with VCFS have a characteristic behavioural phenotype with high rates of behavioural, psychiatric, neuropsychological and communication disorders. Early diagnosis and treatment within a multidisciplinary framework is of paramount importance for VCFS individuals as this will have a major effect in determining the long-term outcome in affected individuals. Longitudinal studies of VCFS children are currently under way to identify precursor symptoms and areas of dysfunction which precede the later development of major psychiatric disorder. Identification of such prodromal features in VCFS may have enormous implications for the clinical management of major psychiatric disorder in VCFS and in the wider population.

A prospective cross-sectional study of speech in patients with the 22q11 deletion syndrome

The purpose of this study was to investigate a consecutive series of 65 participants between 3 and 33 years of age (median age of 9 years and 4 months) with a confirmed 22q11.2 deletion, in order to ascertain the frequency and severity of articulation difficulties, velopharyngeal impairment (VPI), and the level of intelligibility. The majority had velopharyngeal impairment; over half of them to such a degree that surgery had been performed or was considered necessary. A high level of correct place and manner of consonants was only found in children with the 22q11 deletion syndrome from age 6. The most misarticulated consonants were stops and fricatives. Glottal articulation assessed in words and sentences was less frequent than expected according to earlier studies. A high prevalence of reduced intelligibility at different ages indicates an obvious communication limitation in younger children, and for some individuals even as teenagers and adults.

EDUCATIONAL OBJECTIVES

As a result of this activity, the participant will have knowledge about the frequency and severity of: (1) articulation difficulties; (2) velopharyngeal impairment; and (3) the level of intelligibility in patients with a 22q11.2 deletion.

Chromosome 22q11.2 deletion syndrome (DiGeorge and velocardiofacial syndromes)

Chromosome 22q11.2 deletion syndrome occurs in approximately 1 of 3000 children. Clinicians have defined the phenotypic features associated with the syndrome and the past 5 years have seen significant progress in determining the frequency of the deletion in specific populations. As a result, caregivers now have a better appreciation of which patients are at risk for having the deletion. Once identified, patients with the deletion can receive appropriate multidisciplinary care. We describe recent advances in understanding the genetic basis for the syndrome, the clinical manifestations of the syndrome, and new information on autoimmune diseases in this syndrome.