Acoustic assessment of the nasal airway

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.

Changes in the nasalance of vowels within the first week following uvulopalatopharyngoplasty

We conducted a retrospective study to evaluate the short-term effect of uvulopalatopharyngoplasty (UPPP) on changes in the nasalance of five vowels: /a/, /ε/, /i/, /ɔ/, and /u/. Our study group was made up of 20 patients-15 males and 5 females, aged 16 to 57 years (mean: 37.3 ± 11.5)-who had undergone UPPP as a treatment for mild to moderate obstructive sleep apnea. Nasometry was used to obtain nasalance scores in all patients on the morning of the operation (day 1) and subsequently on day 4 or 5 (mean: 4.5 ± 0.5). Preoperatively, nasalance scores were highest for /i/ (mean: 29.8 ± 12.6) and /a/ (mean: 24.1 ± 10.3). After the operation, nasalance scores for all five studied vowels increased; they were highest for /i/ (mean: 40.7 ± +17.8) and /ε/ (mean: 30.0 ± 10.8). The increases in the nasalance of /i/, /ε/, and /u/ were statistically significant (p < 0.05). Our findings indicate that UPPP has a significant impact on nasalance immediately after surgery.

Velar activity in individuals with velopharyngeal insufficiency assessed by acoustic rhinometry

Acoustic rhinometry is routinely used for the evaluation of nasal patency.

OBJECTIVE

To investigate whether the technique is able to identify the impairment of velopharyngeal (VP) activity in individuals with clinical diagnosis of velopharyngeal insufficiency (VPI).

METHODS

Twenty subjects with repaired cleft palate and inadequate velopharyngeal function (IVF) and 18 non-cleft controls with adequate velopharyngeal function (AVF), adults, of both genders, were evaluated. Area-distance curves were obtained during VP rest and speech activity, using an Eccovision Acoustic Rhinometry system. Volume was determined by integrating the area under the curve at the segment corresponding to the nasopharynx. VP activity (ΔV) was estimated by the absolute and relative differences between nasopharyngeal volume at rest (Vr) and during an unreleased/k/ production (Vk). The efficiency of the technique to discriminate IVF and AVF was assessed by a ROC curve.

RESULTS

Mean Vk and Vr values (± SD) obtained were: 23.2 ± 3.6 cm3 and 15.9 ± 3.8 cm3 (AVF group), and 22.7 ± 7.9 cm3 and 20.7 ± 7.4 cm3 (IVF group), corresponding to a mean ΔV decay of 7.3 cm3 (31%) for the AVF group and a significantly smaller ΔV decay of 2.0 cm3 (9%) for the IVF group (p < 0.05). Seventy percent of the IVF individuals showed a ΔV suggesting impaired VP function (below the cutoff score of 3.0 cm3 which maximized both sensitivity and specificity of the test), confirming clinical diagnosis.

CONCLUSION

Acoustic rhinometry was able to identify, with a good discriminatory power, the impairment of VP activity which characterizes VPI.

Delayed closure of the hard palate leads to speech problems and deleterious maxillary growth

BACKGROUND

Hard palate cleft closure has been associated with maxillary hypoplasia. The Schweckendiek procedure offers delayed hard palate closure to avoid early subperiosteal dissection and palatal scarring. This study sought to compare single-stage versus delayed hard palate closure for speech outcome and maxillary growth.

METHODS

A retrospective outcome study was performed of unilateral cleft lip and palate patients with either delayed hard palate repair with a pinned-retained speech prosthesis (Schweckendiek repair) (group 1, delayed hard palate repair, 1978 to 1983) or single-stage cleft palate repair (group 2, single-stage repair, 1983 to 1988). Patients with complete records to maturity at the University of Pittsburgh Cleft Palate Craniofacial Center (n = 82, two equal groups of 41 patients) were studied. Comparative data were collected from multidisciplinary evaluations, perceptual speech scores, speech tests, and cephalometric analysis.

RESULTS

Single-stage cleft palate repair had a lower fistulization rate (11 percent) compared with delayed hard palate repair (58 percent). It also had better speech outcomes compared with delayed hard palate repair: mean speech score, 3.1 versus 7.8; final speech score, 0.9 versus 2.9; velopharyngeal incompetency, 21 percent versus 66 percent; failed video fluoroscopy or nasoendoscopy, 18 percent versus 52 percent; and need for secondary speech procedure, 20 percent versus 63 percent. Single-stage repair showed less maxillary growth disturbance, with class III malocclusion, 31 percent versus 66 percent; cephalometric SNA, 78.2 versus 74.8; need for Le Fort I advancement, 24 percent versus 42 percent; and amount of maxillary advancement required, 6 mm versus 9 mm.

CONCLUSION

The delayed cleft palate repair led to worse speech outcomes; thus, the authors' center abandoned this technique in favor of single-stage repair. In addition, their data showed that the delayed cleft palate repair led to deleterious maxillary growth.

Short- and long-term effect of surgically assisted maxillary expansion on nasal airway size

Transverse maxillary deficiency (TMD) may reduce nasal dimensions and lead to oral breathing. The objective of the present study was to investigate the short- and long-term effects of surgically assisted maxillary expansion on nasal airway size of patients with TMD. Eleven subjects with TMD and skeletal maturity were submitted to posterior rhinomanometry to determine the minimum nasal cross-sectional area (CSA) before and 3, 6, and 12 months after surgery. Subjects were also investigated concerning their habitual diurnal and nocturnal breathing mode (oral, nasal, and oronasal). A statistically significant increase in mean CSA was observed in the early postoperative period (3 months), followed by a decrease to the preoperative levels in the subsequent periods (6 and 12 months). No variations were observed in the breathing mode for 63.6% of the subjects. The results showed that, in the short-term, maxillary expansion most frequently produced an increase in nasal patency. However, it was observed that the effect did not persist over time in most subjects.

Effects of orthognathic surgery on speech and breathing of subjects with cleft lip and palate: acoustic and aerodynamic assessment

OBJECTIVE

To evaluate the impact of orthognathic surgery on acoustic nasalance of subjects with cleft and investigate the causes of possible changes by analyzing velopharyngeal function and nasal patency.

DESIGN/PATIENTS

Nasalance was measured in 29 subjects with operated cleft palate +/- lip before (PRE) and 45 days (POST1) and 9 months (POST2) after surgery, on average. In 19 of the patients, the minimum velopharyngeal (VP) and nasal cross-sectional (N) areas were also determined.

INTERVENTIONS

Le Fort I osteotomy with maxillary advancement in combination with procedures involving the nose, maxilla, mandible or all three.

MAIN OUTCOME MEASURES

Nasalance, VP area, N area.

RESULTS

We observed: (1) a significant (p < .05) increase in mean nasalance at POST1 and POST2, compared with PRE during the reading of oral sentences and nasal sentences; at POST2, high nasalance on the oral sentences was observed in 45% of the patients with normal nasalance at PRE, and 57% of patients with low nasalance on the nasal sentences at PRE no longer presented abnormal nasalance; (2) a significant increase in mean VP area at POST1; two borderline patients demonstrated deterioration of VP closure at POST2, compared with PRE; and (3) a significant increase in mean N area at POST2, with 73% of patients no longer presenting subnormal areas seen at PRE.

CONCLUSIONS

On a long-term basis, orthognathic surgery modifies speech nasalance of some subjects with cleft, perhaps because of an increase in internal nose size. This may also improve nasal patency for breathing.

Nasalance and nasal area values: cross-racial study

Nasometry and nasal cross-sectional area data were obtained from 80 normal male and female speakers (40 African-Americans and 40 white Americans) all of whom were over the age of 18 and spoke the Mid-Atlantic dialect of American English. The nasalance scores for readings of the Zoo Passage did not differ significantly between the groups. However, nasalance scores for readings of the Nasal Sentences were found to be significantly higher among the white speakers. The pressure-flow method was used to obtain nasal cross-sectional area values. There were no racial differences in nasal cross-sectional area. The Nasal Sentences scores were not highly correlated with nasal cross-sectional area. The clinical significance of these findings is discussed.

Acoustic rhinometric measurements of changes in velar positioning

Acoustic rhinometry as a means to detect changes in velar position was examined in this study. Videofluoroscopic recordings were made of two normal speakers maintaining velopharyngeal open and velopharyngeal closed (silent /f/) targets. Simultaneous acoustic rhinometric recordings were made during the production of each stimulus. Determinations of changes in velar positioning during the closed samples were made from fluoroscopic recordings and compared to nasal cavity-nasopharynx changes detected by rhinometry. The excellent agreement between the measures from the two procedures (less than 1 cm) indicates that acoustic rhinometry is capable of detecting changes in velar positioning during "silent" speech. Implications for assessment and future research are discussed.