Maintaining Speech Pressures in the Presence of Velopharyngeal Impairment

Speech and Language Issues in the Cleft Palate Population: The State of the Art

Objective

State-of-the-art activity demands a look back, a look around, and, importantly, a look into the new millennium. The area of speech and language has been an integral part of cleft palate care from the very beginning. This article reviews the development and progression of our knowledge base over the last several decades in the areas of speech; language; anatomy and physiology of the velopharynx; assessment of velopharyngeal function; and treatment, both behavioral and physical, for velopharyngeal problems.

Method

The clear focus is on the cleft palate condition. However, much of what is reviewed applies to persons with other craniofacial disorders and with other underlying causes of velopharyngeal impairment. A major challenge in the next several years is to sort through speech disorders that have a clear anatomic underpinning, and thus are more amenable to physical management, versus those that may be treated successfully using behavioral approaches. Speech professionals must do a better job of finding and applying ways of treating individuals with less severe velopharyngeal impairment, thus avoiding the need for physical management in these persons or ignoring the speech problem altogether.

Conclusion

Early and aggressive management for speech and language disorders should be conducted. For most individuals born with cleft conditions, a realistic goal should be normal speech and language usage by the time the child reaches the school-age years.

Electropalatography for articulation disorders associated with cleft palate

BACKGROUND

Cleft palate is the most common congenital deformity of the face. It could affect speech acquisition, resulting in articulation errors that could persist into adulthood. Electropalatography (EPG) has been used in speech therapy with individuals who have articulation problems that are unresponsive to "standard treatment" procedures.

OBJECTIVES

To determine the effectiveness of speech intervention using electropalatography (EPG) for treating articulation errors in individuals with repaired cleft palate.

SEARCH STRATEGY

The following databases were searched: CENTRAL 2008 (Issue1), MEDLINE 1966 to March 2008, EMBASE 1974 to March 2008, CINAHL 1982 to March 2008, PsycINFO 1967 to March 2008 and eight other databases. We handsearched Clinical Linguistics and Phonetics (1987 to 2008, Issue 2), Cleft Palate Journal/ Cleft Palate-Craniofacial Journal (1980 to 2008, Issue 1), and the International Journal of Language and Communication Disorders (1980 to 2008, Issue 1). We searched the EPG bibliography (Gibbon 2007). We reviewed reference lists of relevant articles and approached researchers to identify other possible published and unpublished studies.

SELECTION CRITERIA

Randomised controlled studies comparing EPG intervention to no treatment, delayed treatment, "standard treatment", or alternative treatment techniques for managing articulation problems associated with cleft palate in children or adults.

DATA COLLECTION AND ANALYSIS

One author searched the titles and abstracts and assessed trial quality. A second author checked judgements; disagreement was resolved through discussion. Three authors were available to examine any potential trials for possible inclusion in the review.

MAIN RESULTS

One trial using parallel design met the inclusion criteria of this review; no meta-analysis was performed. The study reported that fewer therapy sessions were needed to achieve the treatment goals for the EPG therapy and frication display method (N = 2), followed by EPG therapy (N = 2) and "standard treatment" (N = 2).

AUTHORS' CONCLUSIONS

The included trial was a small-scaled study and there were serious limitations in the design and methodology (e.g. allocation concealment was unclear, blinding of outcome assessor(s) was not ensured, few quantitative outcome measures were used, and the results were not reported as planned). Therefore, the current evidence supporting the efficacy of EPG is not strong and there remains a need for high-quality randomised controlled trials to be undertaken in this area.

Clicks produced as compensatory articulations in two adolescents with velocardiofacial syndrome

OBJECTIVE

To report perceptual and dynamic articulatory electropalatography data on clicks produced as compensatory articulations by two adolescents (S1 and S2) with velocardiofacial syndrome and velopharyngeal dysfunction.

RESULTS

The perceptual analysis showed that both speakers produced click substitutions for English targets /t/, /d/, /k/, /g/, and S2 additionally produced clicks for /p/, /b/, and /tintegral/, //. The adolescents produced a range of clicks, which varied in placement (bilabial, dental, alveolar, palatal), voicing (voiced, voiceless), and nasality (nasal, nonnasal). Measurements from the electropalatography data for lingual clicks revealed two articulatory closures, one in the anterior and another in the posterior region of the hard palate. The data revealed how the two closures were timed precisely to produce the click sound. The clicks involved a complex and highly coordinated sequence of tongue maneuvers similar to clicks in some southern African languages.

CONCLUSIONS

Clicks are interpreted as compensatory articulations enabling some speakers with velopharyngeal dysfunction to produce plosive and affricate sounds with perceptually salient acoustic bursts in the oral cavity. Clicks as compensatory articulations merit further systematic investigation, and the procedures reported in this study are considered appropriate for such research.

Nasal airway dimensions of adults with cleft lip and palate: differences among cleft types

OBJECTIVE

To determine the nasal airway dimensions in adults with repaired cleft lip and palate by rhinomanometry and to analyze the reduction associated with different types of clefts.

MODEL

A prospective analysis comparing three types of previously repaired clefts: bilateral cleft lip and palate (BCLP), unilateral cleft lip and palate (UCLP), and isolated cleft palate (CP) at the 5% level of significance.

SETTING

Laboratory of Physiology, Hospital for Rehabilitation of Craniofacial Anomalies, University of São Paulo, Bauru, Brazil.

PARTICIPANTS

Fifty-three subjects aged 18 to 35 years (17 BCLP, 16 UCLP, 20 CP) and a group of 20 individuals without cleft (N).

VARIABLES

Minimum cross-sectional nasal area assessed by posterior (PR) and anterior (AR) rhinomanometry and nasopharyngeal area assessed by modified AR.

RESULTS

Mean (+/- 1 SD) nasal areas obtained by PR were: 0.47 +/- 0.16 cm(2) (BCLP), 0.57 +/- 0.19 cm(2) (UCLP), 0.61 +/- 0.13 cm(2) (CP), and 0.60 +/- 0.10 cm(2) (N). The mean value for the BCLP group was significantly smaller than that for the N and CP groups. The remaining values did not differ from one another. The proportion of subjects with subnormal areas obtained by PR was 41%, 19%, and 0% for groups BCLP, UCLP, and CP, respectively. Similar results were obtained by AR. All subjects presented a nasopharyngeal area larger than 0.80 cm(2), denoting absence of obstruction in the nasopharynx.

CONCLUSIONS

In adulthood BCLP is the type of cleft associated with a greater reduction of nasal airway, compared with UCLP and CP, suggesting that adults with BCLP are at a greater risk for nasal obstruction.

Intraoral Air Pressure Discrimination under Conditions of Experimental Velopharyngeal Insufficiency

Objective

This study assessed a single subject's ability to detect the difference limen (DLs) for his self-generated intraoral air pressure while his oral and nasal cavities were experimentally coupled.

Method

The subject, a 46-year-old man, uses a speech bulb prosthesis to cover an unrepaired cleft of his hard and soft palates. The subject's oral and nasal cavities were experimentally coupled by drilling different size holes through the speech-bulb component of the prosthesis to approximate conditions of velopharyngeal insufficiency. There were four hole-size conditions (10, 15, 20, and 30 mm2), a no-prosthesis condition, and pre- and postbaseline conditions with the prosthesis intact. The subject blew into a tube connected to a pressure transducer and was presented with a series of paired pressure loads. The first pressure load of each pair was the referent (1, 3, or 5 cm H2O), and the second was a preselected comparator load of a different amount. The subject blew into the tube with sufficient force to center the voltage meter's needle at the zero mark. The subject then reported whether the second pressure load required more, less, or equal breath pressure, compared with the referent pressure load of that pair.

Results

Size of the hole coupling the oral/nasal cavities did not significantly affect the subject's difference limen.

Conclusion

Experimental coupling of the oral/nasal cavities did not affect this subject's ability to detect differences in his self-generated intraoral air pressure.

Investigations of a pressure-sensitive theory of marginal velopharyngeal inadequacy

PURPOSE

This two-part project was designed to test a pressure-sensitive theory of marginal velopharyngeal inadequacy (MPVI). Specifically, are select subgroups of children with MPVI perceived as hypernasal because they fail to achieve consistent closure during vowels and semivowels while demonstrating adequate closure during pressure consonants?

METHODS

In part one, 36 children with cleft palate and other craniofacial anomalies were examined using a clinical assessment protocol that included nasometry and perceived ratings of hypernasal resonance. Children with nasalance percentages above threshold during low-pressure (LP) productions and below threshold for high-pressure (HP) productions were placed in one group (group 1), while children with nasalance percentages below threshold for both LP and HP sentences were placed in another (group 2). Children in the two groups were age- and sex-matched. In part two, endoscopic data were examined for 10 additional children who received nasometry, perceived hypernasal resonance scores, and videoendoscopy on the same day and who received higher mean nasalance measures during production of LP sentences than during production of HP sentences.

RESULTS

The results of part one confirmed that children in group 1 were perceived as being significantly more hypernasal than children in group 2 (mean(group 1) = 2.17, mean(group 2) = 1.50; t = 2.75, p =.01). However, results of endoscopic testing failed to demonstrate a consistent observable physiologic pattern of velopharyngeal inadequacy that would confirm the theory that some patients with MVPI are perceived as being hypernasal because of difficulty achieving velopharyngeal closure during vowels and semivowels. CONCLUSIONS; The findings provide partial support for a pressure-sensitive theory of MVPI and demonstrate the value of using both HP and LP sentences to evaluate patients with MVPI.

Relationships between integrated oral-nasal differential pressure and velopharyngeal closure

Oral-nasal differential pressures are derived measures that incorporate both active (e.g., articulatory) and passive (e.g., nasal structure) components. This study was designed to examine integrated oral-nasal differential pressures in speakers with different levels of velopharyngeal closure. Integrated oral-nasal differential pressure data were obtained from 20 noncleft adults with normal speech and 166 speakers with repaired palatal clefts. Velopharyngeal competency for the cleft subjects, as determined by aerodynamic assessment, ranged from adequate to grossly incompetent. Results of the data analysis indicate that integrated pressures are not maintained at a consistent level across all groups. This lack of consistency across all degrees of velopharyngeal opening may reflect the flexibility, as well as structural limitations, of a speech pressure regulating system.

Nasal airway in breathing and speech

Clefts of the lip and palate frequently produce nasal deformities that tend to reduce the size of the nasal airway. Approximately 70% of the cleft population have nasal airway impairment and about 80% "mouth-breathe" to some extent. Surgical correction of nasal, palatal, and pharyngeal structures may further compromise breathing. Type of cleft appears to affect airway size, with unilateral clefts demonstrating the smallest airway. Although a pharyngeal flap may further decrease airway size, some individuals do not notice a postoperative change because of airway compromise prior to flap placement. Speech is a modified breathing behavior that uses the respiratory system to provide an energy source and involves structures within the respiratory tract to modulate this energy into meaningful sounds. The oral, nasal, and pharyngeal structures that are affected by cleft lip and palate during breathing are often compromised for speech as well. The nasal airway plays an important role in controlling speech pressures when velopharyngeal function is impaired. A "good" nose for breathing is often a "bad" nose for speech under such circumstances.

A preliminary study of nasal airway patency and its potential effect on speech performance

The relationship between nasal airway size and articulatory performance was studied in a group of cleft palate patients. Articulation analysis revealed that children with bilateral cleft lip and palate were nearly twice as likely to manifest compensatory articulations as children with unilateral cleft lip and palate or with cleft palate only. When subjects were grouped according to speech performance, aerodynamic assessment indicated that children with compensatory articulations had significantly larger nasal cross-sectional areas than children without compensatory articulations. The findings suggest that children with comparatively large nasal airways may be at increased risk for developing abnormal speech patterns. If these findings are confirmed by further research, such children may be candidates for relatively early palate repair.