Cleft lip and palate care in the United Kingdom--the Clinical Standards Advisory Group (CSAG) Study. Part 3: speech outcomes

An Evaluation of Autologous Fat Injection as a Treatment for Velopharyngeal Insufficiency: A Review and Integrated Data Analysis

BACKGROUND

Velopharyngeal insufficiency (VPI) is a condition characterized by incomplete separation of the oral and nasal cavities during speech production, thereby leading to speech abnormalities and audible nasal emissions. Subsequently, this adversely impacts communication and potentially interpersonal social interactions. Autologous fat grafting (AFG) to the velopharynx, a minimally invasive technique, aims to improve oronasal separation by providing bulk and advancing the posterior pharyngeal wall toward the soft palate. Despite its potential, the relative novelty of AFG in treating VPI has resulted in reporting of inconsistent indications, varied surgical techniques, and mixed outcomes across existing literature.

METHODS

This systemic review examined the evidence of AFG for VPI treatment over the past decade (2013-2023). A thorough search across five electronic databases yielded 233 studies, with 20 meeting the inclusion criteria (e.g., utilized fat injection as their selected VPI treatment, conducted study in human subjects, did not perform additional surgical procedure at time of fat injection). Selected studies encompassed patient and surgical intervention characteristics, perceptual speech assessment (PSA) scores, gap sizes, nasalance measurements, and complications.

RESULTS

The majority of patients had a prior cleft palate diagnosis (78.2%), in which nasoendoscopy was the prevalent method for visualizing the velopharyngeal port defect. Fat harvesting predominantly occurred from the abdomen (64.3%), with an average injection volume of 6.3 mL across studies. PSA and subjective gap size scores were consistently higher preoperatively than postoperatively. PSA score analysis from seven studies revealed significant and sustained improvements postoperatively. Gap size score analysis from four studies demonstrated similar preoperative and postoperative differences. Complications were reported in 17 studies, yielding a 2.7% summative complication rate among 594 cases.

CONCLUSIONS

Autologous fat grafting has emerged as a minimally invasive, safe, and effective treatment for mild to moderate VPI. However, challenges remain because of variability in patient selection criteria, diagnostic modalities, and outcome measurements. This review underscores the need for randomized control trials to directly compare AFG with standard-of-care surgical interventions, providing more conclusive evidence of its clinical efficacy.

Speech and Resonance Disorders in Children With Cleft Palate: Diagnostic Evaluation and Current Speech Therapy Modalities

This article will provide an overview of how speech and resonance can be impacted in children with cleft palate. The authors will outline evidence-based assessment and treatment approaches commonly used for children with cleft palate and provide information on current initiatives to provide speech therapy. The methods discussed will be the use of telehealth to provide access to speech therapy for patients in areas without speech-language pathologists and the use of speech therapy camps to offer intensive, limited-duration speech therapy for groups of children due to the lack of trained providers in certain geographical regions.

Evaluating the Impact of a Global Cleft Speech Mentorship Program on Expanding Practitioner Competency in low- and middle-income countries

A primary challenge in global cleft care lies in the limited opportunities for cleft-specific training and mentorship available to speech practitioners worldwide, particularly in low-income and middle-income countries (LMICs). In addition, the limited number of speech therapists with cleft experience in LMICs creates a significant barrier to access to care for individuals with cleft lip and palate globally. The inaccessibility of cleft-specific clinical instruction and cleft-trained speech therapists impacts the effectiveness of intervention and, subsequently, the speech-language development of cleft-affected individuals worldwide. A structured virtual clinical mentorship program targeting speech practitioners of all skill levels in LMICs was established to address this gap in comprehensive cleft care provision. This article will examine the effectiveness of a structured cleft speech mentorship program in expanding practitioner competency in LMIC communities and, as a result, building capacity for cleft speech care globally. The authors will outline various aspects of the development and implementation of this cleft speech mentorship program, including rationale, participant recruitment, program requirements, and impact assessment tools utilized. An analysis of pre-program and post-program data will be conducted to evaluate the degree to which clinical skills were improved, identify persistent areas of weakness, and examine the effectiveness of the program in expanding speech practitioner competency.

Speech Task Force and Quality of Life after Surgery in Children with Cleft Lip and Palate: Limitation of Professionals

Background  Shortage of speech and language therapists results in lack of speech services. The aims of this study were to find the effectiveness of a combination speech therapy model at Level IV: General speech and language pathologist (GSLP) and Level V: Specific speech and language pathologist (SSLP) in reduction of the number of articulation errors and promotion the quality of life (QoL) for children with cleft palate with or without cleft lip (CP ± L). Methods  Fifteen children with CP ± L, aged 4 years 1 month to 10 years 9 months (median = 76 months; minimum:maximum = 49:129 months) were enrolled in this study. Pre- and post-assessment included oral peripheral examination; articulation tests via Articulation Screening Test, Thai Universal Parameters of Speech Outcomes for People with Cleft Palate, Hearing Evaluation, The World Health Organization Quality of Life Brief_Thai (WHOQOL-BRIEF-THAI) version questionnaire for QoL were performed. Speech therapy included a 3-day intensive speech camp by SSLP, five 30-minute speech therapy sessions by a GSLP, and five 1-day follow-up speech camps by SSLP that provided four 45-minute speech therapy sessions for each child. Results  Post-articulation revealed statistically significant reduction of the numbers of articulation errors at word, sentence, and screening levels (median difference [MD] = 3, 95% confidence interval [CI] = 2-5; MD = 6, 95% CI = 4.5-8; MD = 2.25, 95% CI = 1.5-3, respectively) and improvement of QoL. Conclusion  A speech task force consisting of a combination of Level IV: GSLP and Level V: SSLP could significantly reduce the number of articulation errors and promote QoL.

Divergent growth of the transient brain compartments in fetuses with nonsyndromic isolated clefts involving the primary and secondary palate

Cleft lip/palate is a common orofacial malformation that often leads to speech/language difficulties as well as developmental delays in affected children, despite surgical repair. Our understanding of brain development in these children is limited. This study aimed to analyze prenatal brain development in fetuses with cleft lip/palate and controls. We examined in utero MRIs of 30 controls and 42 cleft lip/palate fetal cases and measured regional brain volumes. Cleft lip/palate was categorized into groups A (cleft lip or alveolus) and B (any combination of clefts involving the primary and secondary palates). Using a repeated-measures regression model with relative brain hemisphere volumes (%), and after adjusting for multiple comparisons, we did not identify significant differences in regional brain growth between group A and controls. Group B clefts had significantly slower weekly cerebellar growth compared with controls. We also observed divergent brain growth in transient brain structures (cortical plate, subplate, ganglionic eminence) within group B clefts, depending on severity (unilateral or bilateral) and defect location (hemisphere ipsilateral or contralateral to the defect). Further research is needed to explore the association between regional fetal brain growth and cleft lip/palate severity, with the potential to inform early neurodevelopmental biomarkers and personalized diagnostics.

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.

Diagnosing and Managing Velopharyngeal Insufficiency in Patients With Cleft Palate After Primary Palatoplasty

Velopharyngeal insufficiency (VPI) after palatoplasty is caused by improper anatomy preventing velopharyngeal closure and manifests as a hypernasal resonance, audible nasal emissions, weak pressure consonants, compensatory articulation, reduced speech loudness, and nostril or facial grimacing. A multidisciplinary team using multimodal instruments (speech analysis, nasoendoscopy, videofluoroscopy, nasometry, and magnetic resonance imaging) to evaluate velopharyngeal function should manage these patients. Careful monitoring of velopharyngeal function by a speech pathologist remains paramount for early identification of VPI and the perceptual assessment should follow a standardized protocol. The greatest methodology problem in CLP studies has been the use of highly variable speech samples making comparison of published results impossible. It is hoped that ongoing international collaborative efforts to standardize procedures for collection and analysis of perceptual data will help this issue. Speech therapy is the mainstay treatment for velopharyngeal mislearning and compensatory articulation, but it cannot improve hypernasality, nasal emissions, or weak pressure consonants, and surgery is the definitive treatment for VPI. Although many surgical methods are available, there is no conclusive data to guide procedure choice. The goal of this review article is to present a review of established diagnostic and management techniques of VPI.

Using "Real-World Data" to Study Cleft Lip/Palate Care: An Exploration of Speech Outcomes from a Multi-Center US Learning Health Network

OBJECTIVE

To assess the ability of a cleft-specific multi-site learning health network registry to describe variations in cleft outcomes by cleft phenotypes, ages, and treatment centers. Observed variations were assessed for coherence with prior study findings.

DESIGN

Cross-sectional analysis of prospectively collected data from 2019-2022.

SETTING

Six cleft treatment centers collected data systematically during routine clinic appointments according to a standardized protocol.

PARTICIPANTS

714 English-speaking children and adolescents with non-syndromic cleft lip/palate.

INTERVENTION

Routine multidisciplinary care and systematic outcomes measurement by cleft teams.

OUTCOME MEASURES

Speech outcomes included articulatory accuracy measured by Percent Consonants Correct (PCC), velopharyngeal function measured by Velopharyngeal Competence (VPC) Rating Scale (VPC-R), intelligibility measured by caregiver-reported Intelligibility in Context Scale (ICS), and two CLEFT-Q™ surveys, in which patients rate their own speech function and level of speech distress.

RESULTS

12year-olds exhibited high median PCC scores (91-100%), high frequency of velopharyngeal competency (62.50-100%), and high median Speech Function (80-91) relative to younger peers parsed by phenotype. Patients with bilateral cleft lip, alveolus, and palate reported low PCC scores (51-91%) relative to peers at some ages and low frequency of velopharyngeal competency (26.67%) at 5 years. ICS scores ranged from 3.93-5.0 for all ages and phenotypes. Speech Function and Speech Distress were similar across phenotypes.

CONCLUSIONS

This exploration of speech outcomes demonstrates the current ability of the cleft-specific registry to support cleft research efforts as a source of "real-world" data. Further work is focused on developing robust methodology for hypothesis-driven research and causal inference.

Where is the Care? Identifying the Impact of Rurality on SLP Caseloads and Treatment Decisions for Children with Cleft Palate

Challenges providing cleft/craniofacial care in rural communities are often reported, leading to disparities in resources available to clinicians. The purpose of this study was to identify the impact of rurality on caseloads and practice patterns of speech-language pathologists (SLPs) regarding speech and velopharyngeal function for children with cleft lip and/or palate (CL/P).

A national, survey of US-based SLPs (N = 359 respondents) investigated resources, comfort level, caseloads, and practice patterns for children with CL/P. Sub-county classifications that delineated levels of rurality were utilized. Descriptive statistics and chi-square analyses were conducted to determine the impact of population density on assessment and referral decisions.

Nearly 83% of SLPs reported providing care for a child with CL/P and 41.4% of these SLPs reported five or more children with CL/P on caseload throughout their career. There were no significant differences in rurality of practice setting and the likelihood of treating a child with CL/P. Significant differences were present between rural, town, suburban, and metropolitan-based SLPs regarding available resources (p = 0.035). SLPs in rural settings reported feeling uncomfortable treating children with CL/P compared to those in metropolitan settings (p = 0.02). Distance to the cleft/craniofacial team and comfort levels impacted referral decisions.

Most SLPs report having children with CL/P on caseload regardless of practice location. Rurality impacted assessment and referral decisions, especially surrounding access to resources and comfort levels engaging in team care. Findings have implications for developing support systems and reducing barriers for rural SLPs working with children born with CL/P.

Speech Outcomes of a National Cohort of Children with Orofacial Cleft at 5 and 10 Years of age

OBJECTIVE

To assess speech outcomes at five and ten years of age in a nationwide study of children with orofacial cleft.

DESIGN

Prospective study.

PARTICIPANTS

Children born with orofacial cleft and having primary surgery in New Zealand. Speech samples were available for 151 five-year-old, and 163 ten-year-old children.

MAIN OUTCOME MEASURES

Intelligibility, Acceptability, Velopharyngeal function, Hypernasality, Hyponasality, severity of airflow evaluated by perceptual speech assessment (using the standardised Rhinocleft assessment), and overall assessment of requirement for clinical intervention.

RESULTS

A large proportion of five-year-old children had speech that was considered to be not completely intelligible, was not acceptable, and had inadequate velopharyngeal function. The noted deficiencies led to a clinical judgement that further speech and/or surgical intervention was required in 85% with cleft lip and palate, 65% with cleft palate and 26% with cleft lip. The proportion of children with poor speech outcomes in the ten-year-old children was lower, though of clinical importance, further intervention required for 25% with CLP, 15% with CP and 3% with CL. The number of sound production errors in both age groups followed the same pattern with fewest in those with CL and most in those with CLP.

CONCLUSIONS

A significant proportion of children with orofacial cleft were found to have poor speech outcomes requiring further treatment. The outcomes are poor compared to centres reported in the UK and Scandinavia. New Zealand requires a review of the current services for individuals born with cleft to improve speech outcomes and interdisciplinary care.

Continuous Multidisciplinary Care for Patients With Orofacial Clefts-Should the Follow-up Interval Depend on the Cleft Entity?

Objective

The multidisciplinary follow-up of patients with cleft lip with or without palate (CL/P) is organized differently in specialized centers worldwide. The aim of this study was to evaluate the different treatment needs of patients with different manifestations of CL/P and to potentially adapt the frequency and timing of checkup examinations accordingly.

Design

We retrospectively analyzed the data of all patients attending the CL/P consultation hour at a tertiary care center between June 2005 and August 2020 (n = 1126). We defined 3 groups of cleft entities: (1) isolated clefts of lip or lip and alveolus (CL/A), (2) isolated clefts of the hard and/or soft palate, and (3) complete clefts of lip, alveolus and palate (CLP). Timing and type of therapy recommendations given by the specialists of different disciplines were analyzed for statistical differences.

Results

Patients with CLP made up the largest group (n = 537), followed by patients with cleft of the soft palate (n = 371) and CL ± A (n = 218). There were significant differences between the groups with regard to type and frequency of treatment recommendations. A therapy was recommended in a high proportion of examinations in all groups at all ages.

Conclusion

Although there are differences between cleft entities, the treatment need of patients with orofacial clefts is generally high during the growth period. Patients with CL/A showed a similarly high treatment demand and should be monitored closely. A close follow-up for patients with diagnosis of CL/P is crucial and measures should be taken to increase participation in follow-up appointments.

Core Outcome Set for Reporting Outcomes of Interventions for Velopharyngeal Dysfunction: Final Results of the COS-VPD Initiative

OBJECTIVE

To date, the recording of outcomes of interventions for velopharyngeal dysfunction (VPD) has not been standardized. This makes a comparison of results between studies challenging. The aim of this study was to develop a core outcome set (COS) for reporting outcomes in studies examining the management of VPD.

DESIGN

A two-round Delphi consensus process was used to develop the COS.

PATIENTS, PARTICIPANTS

The expert Delphi panel comprised patients and caregivers of patients with VPD, surgeons and speech and language therapists specializing in cleft palate, and researchers with expertise in VPD.

INTERVENTIONS

A long list of outcomes was derived from the published literature. In each round of a Delphi survey, participants were asked to score outcomes using the Grading of Recommendations, Assessment, Development, and Evaluations scale of 1 to 9, with 1 to 3 labeled "not important," 4 to 6 labeled "important but not critical," and 7 to 9 labeled "critical."

MAIN OUTCOME MEASURE

Consensus criteria were specified a priori. Outcomes with a rating of 75% or more of the panel rating 7 to 9 and 25% or fewer rating 1 to 3 were included in the COS.

RESULTS

A total of 31 core outcomes were identified from the Delphi process. This list was condensed to combine topic areas to produce a final COS of 10 outcomes, including both processes of care and patient-reported outcomes that should be considered for reporting in future studies of VPD.

CONCLUSIONS

Implementation of the COS-VPD will facilitate consistency of outcomes data collection and comparison of results across studies.

Speech input processing in children born with cleft palate: A systematic literature review with narrative synthesis

BACKGROUND

Speech development requires intact and adequately functioning oral anatomy and cognitive 'speech processing' skills. There is evidence that speech input processing skills are associated with speech output problems in children not born with a cleft. Children born with cleft palate ± lip (CP±L) are at high risk of developing disordered speech output. Less is known about their speech input processing skills and whether they are associated with cleft-related speech sound disorder (SSD).

AIMS

(1) To collate and evaluate studies reporting evidence regarding the speech input processing skills of children born with cleft palate in comparison with data from typically developing children or other comparison groups; and (2) to identify any available evidence regarding relationships between speech input processing skills and speech output in children born with CP±L.

METHODS & PROCEDURES

Potentially relevant studies published up to November 2019 were identified from the following databases: Medline via Ovid, Embase via Ovid, Cinahl via Ebscohost, PsycInfo via Ebscohost, BNI via ProQuest, AMED via Ovid, Cochrane Library and Scopus. Inclusion criteria were: peer-reviewed articles published in scientific journals, any design, published in English, participants born with a CP±L aged up to age 18 years who completed speech input processing assessments compared with normative data and/or a control or other comparison group. Critical Appraisal Skills Programme (CASP) checklists were used to quality appraise included studies.

OUTCOMES & RESULTS

Six studies were retained in the final review. There is some evidence that children born with CP±L perform less well than non-cleft controls on some speech input processing tasks and that specific input processing skills may be related to errors in the children's speech. Heterogeneity in relation to study groups and assessments used, as well as small sample sizes, limits generalization of findings.

CONCLUSION & IMPLICATIONS

There is limited evidence regarding the speech input processing skills of children born with CP±L. There are indications that children born with CP+/L may have difficulty in some aspects of speech input processing in comparison with children not born with a cleft, and that difficulties with some speech input processing tasks may be specific to errors in children's speech output. Further research is required to develop our understanding of these skills in this population and any associations with speech output.

WHAT THIS PAPER ADDS

What is already known on the subject Few studies have been published that examine aspects of speech input processing in children born with CP±L. Theoretical models of speech processing, and published studies, propose that speech input processing skills are associated with SSD in children who were not born with a cleft. However, it is less clear whether there is any association between speech input processing and cleft-related SSD. What this paper adds to existing knowledge This review systematically collates and evaluates the published, peer-reviewed evidence regarding speech input processing skills in children born with CP±L. The collated evidence indicates that some speech input processing skills differ between children with and without CP±L. There is some evidence, from a single study, that speech input processing of specific cleft speech characteristics (CSCs) may be associated with the presence of these CSCs in the speech output of some children born with CP±L. What are the potential or actual clinical implications of this work? While the evidence is currently limited, increasing our knowledge of speech input processing skills in children born with CP±L contributes to our clinical understanding of the nature of cleft-related SSD. The current evidence suggests that speech and language therapists should consider speech input processing skills when assessing children with cleft-related SSD to support intervention planning. Considering these skills in relation to literacy development in these children may also be important.

Assessment of Intelligibility in Children with Velopharyngeal Insufficiency: The Relationship between Intelligibility in Context Scale and Experimental Measures

PURPOSE

The purpose of this study was to investigate the clinical application of the Intelligibility in Context Scale (ICS) instrument in children with velopharyngeal insufficiency (VPI). This study investigated the relationship between clinical speech outcomes and parental reports of speech intelligibility across various communicative partners.

METHODS

The ICS was completed by the parents of 20 English-speaking children aged 4-12 years diagnosed with VPI. The parents were asked to rate their children's speech intelligibility across communication partners using a 5-point scale. Clinical metrics obtained using standard clinical transcription on the Picture-Cued SNAP-R Test were: (1) percentage of consonants correct (PCC), (2) percentage of vowels correct (PVC), and (3) percentage of phonemes correct (PPC). Nasalance from nasometer data was included as an indirect measure of nasality. Intelligibility scores obtained from naive listener's transcriptions and speech-language pathologists' (SLP) ratings were compared with the ICS results.

RESULT

Greater PCC, PPC, PVC, and transcription-based intelligibility values were significantly associated with higher ICS values, respectively (r[20] = 0.84, 0.82, 0.51, and 0.70, respectively; p < 0.05 in all cases). There was a negative and significant correlation between ICS mean scores and SLP ratings of intelligibility (r = -0.74; p < 0.001). There was no significant correlation between ICS values and nasalance scores (r[20] = -0.28; p = 0.22).

CONCLUSION

The high correlations obtained between the ICS with PCC and PPC measures indicate that articulation accuracy has had a great impact on parents' decision-making regarding intelligibility in this population. Significant agreement among ICS scores with naive listener transcriptions and clinical ratings supports use of the ICS in practice.

The Relationship Between Maxillary Growth and Speech in Children With a Unilateral Cleft Lip and Palate at 5 Years of Age

OBJECTIVE

This study sought to investigate the association between maxillary growth and speech outcomes for children with a repaired unilateral cleft lip and palate (UCLP) at 5 years of age.

PARTICIPANTS

In all, 521 children (180 females and 341 males) with a nonsyndromic complete UCLP, born between 2007 and 2012 in England, Wales, and Northern Ireland were included in this study.

OUTCOME MEASURES

Maxillary growth was analyzed using dental models scored by the 5-Year-Olds' index, and perceptual speech analyses were scored by the Cleft Audit Protocol for Speech - Augmented rating.

RESULTS

Forty-one percent of the children achieved good maxillary growth (scores 1 and 2 on 5-Year-Old' index). Fifty percent of the children achieved normal speech (achieving UK speech standard 1). Maxillary growth was not found to have an impact on speech outcome when described by the 3 UK National Cleft Lip and Palate Speech Audit Outcome Standards. Analysis according to individual speech parameters showed dentalizations to be less prevalent in children with good maxillary growth compared to fair and poor growth (P = .001). The remaining speech parameters within resonance, nasal airflow, and articulation categories were not significantly associated with maxillary growth.

CONCLUSION

The findings from this study suggest that children with a history of complete UCLP, who have poor maxillary growth, are not at a higher risk of having major speech errors compared to children with good or fair maxillary growth at 5 years of age.

Intelligibility in 3-Year-Olds With Cleft Lip and/or Palate Using the Intelligibility in Context Scale: Findings from the Cleft Collective Cohort Study

Objective:

To provide comparison data on the Intelligibility in Context Scale (ICS) for a sample of 3-year-old English-speaking children born with any cleft type.

Design:

Questionnaire data from the Cleft Collective Cohort Study were used. Descriptive and inferential statistics were carried out to determine difference according to children’s cleft type and syndromic status.

Participants:

A total of 412 children born with cleft lip and/or palate whose mothers had completed the ICS when their child was 3 years old.

Main Outcome Measure(s):

Mothers’ rating of their children’s intelligibility using the ICS.

Results:

The average ICS score for the total sample was 3.75 ( sometimes-usually intelligible; standard deviation [SD] = 0.76, 95% CIs = 3.68-3.83) of a possible score of 5 ( always intelligible). Children’s speech was reported to be most intelligible to their mothers (mean = 4.33, SD = 0.61, 95% CIs = 4.27-4.39) and least intelligible to strangers (mean = 3.36, SD = 1.00, 95% CIs = 3.26-3.45). There was strong evidence ( P < .001) for a difference in intelligibility between children with cleft lip only (n = 104, mean = 4.13, SD = 0.62, 95% CIs = 4.01-4.25) and children with any form of cleft palate (n = 308, mean = 3.63, SD = 0.76, 95% CIs = 3.52-3.71). Children born with cleft palate with or without cleft lip and an identified syndrome were rated as less intelligible (n = 63, mean = 3.28, SD = 0.85, 95% CIs = 3.06-3.49) compared to children who did not have a syndrome (n = 245, mean = 3.72, SD = 0.71, 95% CIs = 3.63-3.81).

Conclusions:

These results provide preliminary comparative data for clinical services using the outcome measures recommended by the International Consortium for Health Outcomes Measurement.

Protocol for the development of a core outcome set for reporting outcomes of management of velopharyngeal dysfunction

INTRODUCTION

Velopharyngeal dysfunction (VPD) is present in up to 40% of patients following cleft palate repair. Children with VPD display hypernasal speech, nasal air emission and are at a high risk for developing articulation disorders. The overall result is decreased intelligibility and acceptability of speech, as well as significant functional and social impairments. Although there are several surgical approaches for the management of children with VPD, standard treatment protocols have not been well defined. There is a need for a core outcome set (COS) to reduce outcome reporting bias and heterogeneity across studies of VPD. The COS-VPD Initiative is an international effort to establish a COS for the reporting of studies of the management of VPD.

METHODS AND ANALYSIS

The study has been developed according to the Core Outcome Set-STAandards for Development standards for the design of a COS study and will be carried out according to the guidance of the Core Outcome Measures in Effectiveness Trials (COMET) initiative. A long list of clinical and patient-reported outcomes will be identified from a systematic review of the literature. A two-stage Delphi consensus process will be used to refine this list into a COS. An international panel of key stakeholders including patients, parents and multidisciplinary clinical and academic experts will be invited to participate in this process. Consensus criteria will be specified a priori and the steering group will ratify the final COS.

ETHICS AND DISSEMINATION

The study has ethical approval through Children's Health Ireland at Crumlin Research and Ethics Committee, Ref: GEN/683/18. The study is registered with the COMET Initiative (http://www.cometinitiative.org/studies/details/1146?result=true). The COS will be disseminated by publication in the peer-reviewed literature, presentation at international research meetings and distribution to patient-representative organisations. This will facilitate the application of the COS in future studies of the management of VPD.

Sociodemographic Predictors of Patient Age at Time of Cleft Lip and Palate Repair

Objective:

To identify the impact of sociodemographic and health variables on the age at which patients undergo cleft lip repair, cleft palate repair, and primary speech evaluation.

Design:

A retrospective, noninterventional quality assessment, and quality improvement study was designed.

Setting:

This institutional study was performed at Michigan Medicine in Ann Arbor, MI.

Patients:

All patients born between 2011 and 2014 who received surgical cleft repair, excluded those who were adopted (n = 165).

Main Outcome Measure:

The age at which patients undergo cleft lip repair, cleft palate repair, and primary speech evaluation.

Results:

Cleft lip repair was performed significantly later for patients identifying as Asian (18 weeks, P = .01), patients with Child Protective Services contact (19 weeks, P = .01), patients with a significant comorbidity (14 weeks, P = .02), and patients who underwent preliminary lip adhesion surgery (19 weeks, P < .01). Cleft palate repair was performed significantly later for patients identifying racially as Asian (19 weeks, P = .03) and other (22 weeks, P = .03). Preliminary speech and language evaluation were performed significantly later for patients identifying as black (55 weeks, P = .03) and patients diagnosed with an isolated cleft lip (71 weeks, P < .01).

Conclusions:

Timing of cleft lip, cleft palate repair, and primary speech and language evaluation are subject to variation which may be predicted by clinically accessible factors. By identifying race, Child Protective Services contact, and care variables as significant predictors of increased patient age at time of intervention, multidisciplinary cleft care teams can proactively allocate patient support resources.

Facilitators and Barriers to Implementing Standardized Outcome Measurement for Children With Cleft Lip and Palate

OBJECTIVE

Identify facilitators and barriers to implementing standardized outcome measurement in cleft care.

DESIGN

Cross-sectional, qualitative study.

SETTING/PARTICIPANTS

Participants included 24 providers and staff from a large, multidisciplinary cleft team in the southwest United States, 5 caregivers of children with cleft palate (with or without cleft lip) treated by this team, and 3 experts involved in implementing a cleft-specific standardized outcome measurement in the United Kingdom.

INTERVENTIONS

Semistructured, qualitative interviews were conducted exploring perceived facilitators and barriers to implementing standardized outcome measurement in cleft care. Interviews were audio-recorded, transcribed, and analyzed for content. The Consolidated Framework for Implementation Research was used to guide the interviews and analysis. The analysis focused on the characteristics of standardized outcome measurement that directly influence its adoption.

RESULTS

Participants identified both facilitators and barriers to implementing standardized outcome measurement. Facilitators included the strength and quality of evidence supporting improvements in cleft care delivery following implementation of standardized outcome measurement and the relative advantage of standardized outcome measurement over continuing the status quo. Barriers included the difficulty adapting standardized outcome measurement to meet local context and patient-specific needs and the complexity of implementing standardized outcome measurement.

CONCLUSIONS

Providers, staff, and caregivers involved in cleft care perceive multiple benefits from standardized outcome measurement, while also recognizing substantial barriers to its implementation. Results from this study can be used to guide development of an implementation strategy for standardized outcome measurement that builds upon perceived strengths of the intervention and reduces perceived barriers.

The Trend of Cleft Care at a Children's Referral Center in Thailand

OBJECTIVE

To investigate the trend in cleft care at a major children's referral center in Bangkok, Thailand.

STUDY DESIGN

Retrospective chart review.

PATIENTS AND METHODS

A review of 129 patients under 18 years of age who had underwent care by the senior author for cleft treatment between January 2015 and October 2017 was done. The impact of varying factors on patient care was analyzed. We compare our demographics and treatment timeline to that of previously published literature in more developed countries.

SETTING

Tertiary care medical center.

RESULTS

One hundred and two patient charts were reviewed with 53% male patients. Most patients had both cleft lip and cleft palate, 44%. Cleft lips most commonly were complete and occurred on the left side. In all, 77.4% of clefts were nonsyndromic. On average, primary cleft lip surgery was delayed being performed about 11 months of age. Sixteen percent of patients were treated with an obturator, while 11 patients had nasoalveolar molding use. Hearing screenings occurred on average at around 6 months of age. Abnormal tympanograms were evident in 32% of individuals. There was a significant difference in timing of surgery for patients who lived a distance greater than 30 kilometers from the hospital versus those from the Bangkok metropolis (P < .05).

CONCLUSION

Reviewing data from a high-volume referral center in Thailand reveals mild variance with regard to cleft care timing compared to published literature from the developed world. Distance traveled was found to impact timing of surgery.

Benchmarking Speech, Velopharyngeal Function Outcomes and Surgical Characteristics Following the Sommerlad Protocol and Palate Repair Technique

Objective:

To report speech and velopharyngeal function (VPF) outcomes, and surgical characteristics, at age 5 following early complete palate closure using the Sommerlad protocol.

Design:

A retrospective, descriptive, cross-sectional consecutive series.

Setting:

A regional twin site center; a district general hospital and tertiary children’s hospital.

Participants:

Between 1993 and 2006, 877 participants underwent surgery; 712 (81%) were eligible for inclusion; 391 (55%) were included, 321 (45%) excluded. Thirteen percent had bilateral cleft lip and palate (CLP), 40% unilateral CLP, and 47% isolated cleft palate.

Intervention:

Lip and vomerine flap repair at 3 months of age (BCLP, UCLP) with soft palate closure using radical muscle dissection and retropositioning at a mean age of 6.6 months, range 4 to 23 months, as described and undertaken by Sommerlad.

Outcome Measures:

Velopharyngeal Composite (VPC) CAPS-A and articulation summary scores derived from analysis using the Cleft Audit Protocol for Speech-Augmented.

Results:

A VPC-SUM CAPS-A score of “0” was found in 97% reflecting adequate VPF; 73% had no cleft articulation difficulties. The BCLP group had the poorest articulation. Secondary speech surgery rate was 2.6% and 10.7% had fistula repair. Levator muscle quality and degree of retropositioning was associated with speech outcomes related to VPF. 2.6% had current features of VPI.

Conclusions:

Complete palate closure by around 6 months of age by the surgeon who described the technique led to excellent perceived VPF and very good speech outcomes at age 5, with less speech therapy and secondary speech surgery than commonly reported. These findings serve as a benchmark for the Sommerlad protocol and technique.

Velopharyngeal Closure and Resonance in Children Following Early Cleft Palate Repair: Outcome Measurement

Introduction Timing of cleft palate repair and the method of speech outcome measurement in children with cleft lip and palate are much debated topics. The associated problems and quality of life in these children depend on the timing of the surgery.

Aim The aim of this study was to investigate the velopharyngeal (VP) function and resonance parameters in children following early cleft palate repair.

Method A total of 25 Kannada-speaking children with early repaired cleft palate were subjected to speech assessment and videofluoroscopic assessment. Perceptual speech parameters measured were severity of hypernasality and presence of nasal air emission. Videofluoroscopy was interpreted in terms of closure ratios to predict the severity of VP dysfunction.

Results The analysis of videofluoroscopic images indicated that 48% of children had complete VP closure and 52% had perceptually normal resonance. A good correlation was found between the closure ratio and hypernasality.

Conclusion Understanding the perceptual speech parameters and their structural correlates for outcome measurement will give better evidence for refining the existing treatment protocols. Data on a larger population are warranted for establishing predictors of optimum speech outcome.

Closer to the Truth on National Fistula Prevalence After Unilateral Complete Cleft Lip and Palate Repair? The Cleft Care UK Study

Objectives:

To (1) determine the prevalence of nonperialveolar palatal fistula up to age 5 following repair of unilateral cleft lip and palate (UCLP) in the United Kingdom, (2) examine the association of palatoplasty techniques with fistula occurrence, and (3) describe the frequency of fistula repairs and their success.

Design:

Cross-sectional study.

Setting:

All 11 centralized regional cleft centers in the United Kingdom.

Participants:

Two hundred sixty-eight children born between 2005 and 2007 recruited by Cleft Care UK, a nationwide cross-sectional study of all 5-year-old children born with nonsyndromic UCLP.

Main Outcome Measure:

Nonperialveolar palatal fistula prevalence up to age 5.

Results:

Fistulas were found in 72 children (31.3%, 95% confidence interval: 25.4%-37.7%) and had no significant association with palate repair sequences. Twenty-four fistulas were repaired by age 5, 12 of which had data showing 10 (83.3%) successful repairs.

Conclusion:

The prevalence of nonperialveolar fistulas following primary palatoplasty of UCLP in the United Kingdom was higher than previously reported. This information should be part of the preoperative discussion with families. Prospective collection of the presence of fistulas will be necessary before we can associate the occurrence of fistulas with a surgeon, institution, surgical technique, or protocol of care.

Recommendations for the Development and Reform of Microtia and Atresia Services

BACKGROUND

The initial step in setting up standardized microtia-atresia service is investigating the current status of the service and comparing this to internationally recognized guidelines or care standards. In many countries, documented information about microtia care is lacking. This study is an initiative to guide reform efforts of national microtia service in any country. The UK care standards for microtia-atresia can be a useful model to help set up a comprehensive microtia-atresia service.

METHODS

The authors conducted a survey to investigate different aspects of microtia service in Egypt. The major plastic surgery centers (n = 22) were surveyed by a structured questionnaire. The results were compared with the UK care standards for microtia-atresia to identify the aspects that need improvement. Thorough analysis of the main problems in microtia-atresia service is presented.

RESULTS

The authors found that microtia service is fragmented between the surveyed centers with 65% of the centers treating less than 10 microtia cases annually. Multiple surgeons are responsible for ear reconstruction in 90% of centers and only 25% of them practise a multidisciplinary team approach. None of the centers uses validated tools of aesthetic or psychological patient-reported outcome measures.

RECOMMENDATIONS

These 5 recommendations are the keys to reforming microtia service in any country:(1) Establishing nationally designated centers to concentrate the required expertise.(2) Assigning fewer high-volume surgeons to optimize the surgical outcomes.(3) Providing treatment by experienced multidisciplinary teams.(4) Using validated tools of patient-reported outcome measures.(5) Collecting and keeping standardized records for regular audit and intercenter studies.

Effects of Error Experience on Learning to Lower Speech Nasalance Level

Purpose This research aims to examine the effects of error experience when learning to speak with lowered nasalance level. Method A total of 45 typical speakers were instructed to learn to lower speech nasalance level in either an errorless (restricted possibility for committing errors) or an errorful (unrestricted possibility for committing errors) learning condition. The nasality level of the participants' speech was measured by a nasometer and quantified by nasalance scores (in percent). Errorless learners practiced producing speech with lowered nasalance level with a threshold nasalance score of 50% (the easiest target) at the beginning, which gradually decreased to a threshold of 10% (the most difficult target) at the end. The same set of threshold targets was presented to errorful learners, but in reverse order. Errors were defined by the proportion of speech, with a nasalance score exceeding the threshold. Retention and transfer tests were administered. Results Errorless learners displayed fewer errors and lower mean nasalance scores than errorful learners during the acquisition phase. Furthermore, errorless learners achieved lower mean nasalance scores than errorful learners in the retention and transfer tests. Conclusion These results suggest that errorless learning is more effective than errorful learning and that error experience has a detrimental effect on the acquisition of a novel speech motor task that requires minimization of the nasality level. Errorless learning may be a useful paradigm for the intervention and management of hypernasality in clinical settings where behavioral treatments are needed.

The incidence of velopharyngeal insufficiency and oronasal fistula after primary palatal surgery with Sommerlad intravelar veloplasty: A retrospective study in Isfahan Cleft Care Team

OBJECTIVES

This study was designed to determine the incidence of velopharyngeal insufficiency (VPI), oronasal fistula development and facial grimace in patients seen by Isfahan Cleft Care Team (ICCT) after primary Sommerlad intravelar veloplasty (SIVV). Furthermore the association of gender, cleft type and age at primary surgery with the incidence of hypernasality and fistula is determined.

METHODS

A group of 40 patients with history of cleft palate with or without cleft lip were identified from the records of ICCT between 2011 and 2014. The main outcome measures were the incidence of hypernasality and fistula after primary palate repair with SIVV. Speech recordings were analyzed by consensus by two speech therapists according to the Cleft Audit Protocol for Speech- Augmented (CAPS-A), (Kappa = 82.4). Deciding whether or not to have a fistula was based on the oral examination videos.

RESULTS

Severe and moderate hypernasality was observed in 42.5% of patients. Normal resonance and mild/borderline hypernasality was observed in 37.5% and 20% of patients, respectively. The frequency of fistulas was 7.5%. There was a significant association between hypernasality with cleft type and the age at primary surgery (p < 0.05).

CONCLUSION

Significant progress has been made in the outcomes of the primary palate surgeries with the SIVV technique compared to the previous study in the ICCT.

Improving the accuracy of automated cleft speech evaluation

An automated cleft speech evaluator, available globally, has the potential to dramatically improve quality of life for children born with a cleft palate, as well as eliminating bias for outcome collaboration between cleft centers in the developed world. Our automated cleft speech evaluator interprets resonance and articulatory cleft speech errors to distinguish between normal speech, velopharyngeal dysfunction and articulatory speech errors. This article describes a significant update in the efficiency of our evaluator. Speech samples from our Craniofacial Team clinic were recorded and rated independently by two experienced speech pathologists: 60 patients were used to train the evaluator, and the evaluator was tested on the 13 subsequent patients. All sounds from 6 of the CAPS-A-AM sentences were used to train the system. The inter-speech pathologist agreement rate was 79%. Our cleft speech evaluator achieved 85% agreement with the combined speech pathologist rating, compared with 65% agreement using the previous training model. This automated cleft speech evaluator demonstrates good accuracy despite low training numbers. We anticipate that as the training samples increase, the accuracy will match human listeners.

Collection of Bilateral Cleft Lip and Palate Standard Set Variables: Establishing a Baseline

Background

The International Consortium for Healthcare Outcomes Measurement recently published a consensus Standard Set of clinical and patient-centered metrics to measure outcomes for patients with cleft lip and/or palate (CLP). This study aims to evaluate how the Standard Set compares to existing data collected to anticipate the impact that the Standard Set may have on quality and quantity of outcome data.

Methods

Extraction of the Standard Set data points was attempted retrospectively for all nonsyndromic patients with bilateral cleft lip and/or palate who underwent primary lip and/or palate repair by a single surgeon (JGM) between June 2007 and June 2014.

Results

Bilateral cleft lip repair was performed on 32 patients of which 29 also underwent palate repair. All but one of the baseline demographic and phenotypic variables were available. All perioperative variables were collected, but data quality was heterogeneous. There were no early complications. At 5 years, 29.6% of patients were lost to follow-up; however, a degree of data was available on 11 of the 12 clinical metrics for those remaining. Of patients with Veau IV cleft palate and follow-up at age 5, 1 patient (6.7%) had an oronasal fistula and 1 had velopharyngeal incompetence requiring Furlow palatoplasty (6.7%). No patient-reported data were collected for any time point.

Conclusion

Prospective collection of the International Consortium for Healthcare Outcomes Measurement Standard Set will improve consistency of clinical data and add the patient perspective currently lacking in outcome measures collected for patients with bilateral cleft.

Problems With Reliability of Speech Variables for Use in Quality Registries for Cleft Lip and Palate—Experiences From the Swedish Cleft Lip and Palate Registry

Objective:

To test the reliability of the speech data in the Swedish quality registry for cleft lip and palate.

Design:

Retrospective study.

Setting:

Primary care university hospital.

Participants:

Ninety-four children born with cleft palate with or without cleft lip between 2005 and 2009 who had been assessed and registered in the quality registry at the age of 5 years.

Main Outcome Measures:

Data in the registry on percent oral consonants correct, percent oral errors, percent nonoral errors, perceived velopharyngeal function (PVPF), and intelligibility were compared with results based on reassessments by 3 independent raters from audio recordings. Agreement was calculated by the intraclass correlation coefficient (ICC), quadratic weighted kappa, and percentage agreement.

Results:

Absolute agreement calculated by average measures ICC for percent oral consonants correct, percent oral errors, and percent nonoral errors was above >0.90. Single measures ICC for percent oral consonants correct was 0.82, for percent oral errors 0.69, and for percent nonoral errors 0.83. The kappa coefficient for PVPF was 0.5 to 0.59 and for intelligibility 0.65 to 0.77. Exact percentage agreement for PVPF was 33% and for intelligibility 47.8%.

Conclusions:

The data on oral consonants correct and nonoral errors in the quality registry seem to be reliable. The data on oral errors, PVPF, and intelligibility should be interpreted with caution. If differences among treatment centers are detected, one should go back and examine the collected raw data before drawing any definitive conclusions about treatment outcome.

Cleft Care UK study. Part 5: child psychosocial outcomes and satisfaction with cleft services

Objectives

To describe the impact of cleft service centralization on parental perceptions of child outcomes and satisfaction with care from the Cleft Care UK (CCUK) study and compare them to the Clinical Standards Advisory Group (CSAG) study that took place 15 years earlier.

Setting and Sample Population

A subgroup of respondents from a UK multicentre cross-sectional study (CCUK) of 5-year-olds born with non-syndromic unilateral cleft lip and palate.

Materials and Methods

Data on parents’ perceptions of child self-confidence and their satisfaction with treatment outcomes and service provision were collected via self-report questionnaires. Data were compared with findings from the 1998 CSAG study.

Results

Fewer parents in the CCUK study perceived their children as having poor self-confidence than in the 1998 CSAG study (8 and 19%, respectively). At least 81% of parents report satisfaction with the child’s facial features after surgery and 98% report being satisfied with the care received. These results are similar to those reported in 1998. There is no evidence of an adverse impact on families’ ability to attend appointments at the cleft clinic following centralization. Levels of reported problems (around 30%) with attendance were similar to those reported by CSAG.

Conclusion

Centralization of cleft services appears to have improved parental perceptions of some child outcomes but has made little difference to already high levels of parental satisfaction with cleft care services. Centralization is not associated with an increase in the proportion of families who find it difficult to attend appointments.

Centralization of cleft care in the UK. Part 6: a tale of two studies

Objectives

We summarize and critique the methodology and outcomes from a substantial study which has investigated the impact of reconfigured cleft care in the United Kingdom (UK) 15 years after the UK government started to implement the centralization of cleft care in response to an earlier survey in 1998, the Clinical Standards Advisory Group (CSAG).

Setting and Sample Population

A UK multicentre cross-sectional study of 5-year-olds born with non-syndromic unilateral cleft lip and palate. Data were collected from children born in the UK with a unilateral cleft lip and palate between 1 April 2005 and 31 March 2007.

Materials and Methods

We discuss and contextualize the outcomes from speech recordings, hearing, photographs, models, oral health and psychosocial factors in the current study. We refer to the earlier survey and other relevant studies.

Results

We present arguments for centralization of cleft care in healthcare systems, and we evidence this with improvements seen over a period of 15 years in the UK. We also make recommendations on how future audit and research may configure.

Conclusions

Outcomes for children with a unilateral cleft lip and palate have improved after the introduction of a centralized multidisciplinary service, and other countries may benefit from this model. Predictors of early outcomes are still needed, and repeated cross-sectional studies, larger longitudinal studies and adequately powered trials are required to create a research-led evidence-based (centralized) service.

A cross-sectional survey of 5-year-old children with non-syndromic unilateral cleft lip and palate: the Cleft Care UK study. Part 1: background and methodology

Objectives

We describe the methodology for a major study investigating the impact of reconfigured cleft care in the United Kingdom (UK) 15 years after an initial survey, detailed in the Clinical Standards Advisory Group (CSAG) report in 1998, had informed government recommendations on centralization.

Setting and Sample Population

This is a UK multicentre cross-sectional study of 5-year-olds born with non-syndromic unilateral cleft lip and palate. Children born between 1 April 2005 and 31 March 2007 were seen in cleft centre audit clinics.

Materials and Methods

Consent was obtained for the collection of routine clinical measures (speech recordings, hearing, photographs, models, oral health, psychosocial factors) and anthropometric measures (height, weight, head circumference). The methodology for each clinical measure followed those of the earlier survey as closely as possible.

Results

We identified 359 eligible children and recruited 268 (74.7%) to the study. Eleven separate records for each child were collected at the audit clinics. In total, 2666 (90.4%) were collected from a potential 2948 records. The response rates for the self-reported questionnaires, completed at home, were 52.6% for the Health and Lifestyle Questionnaire and 52.2% for the Satisfaction with Service Questionnaire.

Conclusions

Response rates and measures were similar to those achieved in the previous survey. There are practical, administrative and methodological challenges in repeating cross-sectional surveys 15 years apart and producing comparable data.

Speech intelligibility after repair of cleft lip and palate

Background: Intelligibility refers to understandability of speech; and lack of it can negatively affect children’s overall communication effectiveness. Children with repaired cleft lip and/or cleft palate (CL/P) may experience poor speech intelligibility. This study aimed at evaluating speech intelligibility in children with repaired CL/P who had not been referred to speech-language pathology clinics for early intervention.

Methods: Sixty-four monolingual Persian-speaking children, 32 children with repaired CL/P, and 32 controls aged 3 to 5 years participated in this survey. Their speech intelligibility was evaluated through the Persian Speech Intelligibility Test and was normalized on children 3 to 5 years. Each speech sample was heard by a speech and language pathologist (SLP), as well as 2 nonprofessional listeners. Two objective measures of speech intelligibility including Percentage of Consonants Correct (PCC) and Percentage of Intelligible Words (PIW) were used in this research.

Results: Children with CL/P were significantly outperformed by their peers in PCC (p= 0.0001) and PIW (p= 0.0001). More than half of the case group had compensatory errors and 40.6% had obligatory errors. The PCC and the PIW were statistically different in children with different rates of hyper nasality (p= 0.001).

Conclusion: Speech intelligibility of children with CL/P is impaired due to their articulation disorders (obligatory and compensatory errors). This survey documents the necessity for speech therapy for increasing speech intelligibility in this population.

A Cross-Sectional Study of Speech in 10-Year-Old Children with Cleft Palate: Results and Issues of Rater Reliability

Objectives:

To describe speech based on perceptual evaluation in a group of 10-year-old children with cleft palate. A secondary aim was to investigate the reliability of speech-language pathologists’ perceptual assessment of cleft palate speech.

Design:

Retrospective cross-sectional study in children with cleft palate. External raters made assessments from randomized speech recordings.

Subjects:

Thirty-eight children with unilateral cleft lip and palate (UCLP) or cleft palate only (CPO) and 10 children in a comparison group.

Main Outcome Measures:

Ratings of hypernasality, hyponasality, audible nasal air leakage, weak pressure consonants, and articulation. Exact agreement and weighted kappa values were used for reliability.

Results:

Hypernasality was found in 25% of children with a cleft of the soft palate (CSP), 33% of children with a cleft of the hard and soft palate (CHSP), and 67% of children with a UCLP. Similar results were found for audible nasal air leakage. Articulation errors were found in 6% of the CHSP group and 25% of the UCLP group, whereas no child in the CSP group had articulation errors. The reliability was moderate to good for different variables, with lowest values for hypernasality.

Conclusions:

Speech results in this series seem less satisfactory than those reported in other published international studies, but it is difficult to draw any certain conclusions about speech results because of large methodological differences. Further developments to ensure high reliability of perceptual ratings of speech are called for.

Centralization of Services: Standard Setting and Outcomes

Objective

To test specific standards set in the newly established cleft lip and palate service in three regions of the U.K. The standards relate to record collection and outcomes.

Design

Retrospective analysis.

Patients

Records of 31 children, 5 years of age, who were born in 1997 with complete unilateral clefts of lip and palate and were treated by surgeons in three regions.

Main outcome measures

Record collection standards were measured by collecting dental study models. Outcomes were measured with the 5-Year-Old Index.

Results

Of the 31 subjects, 52% had excellent and good outcomes. The 31 cases represented 62% of the total records collected.

Conclusions

The three regions examined fell short of the standards set, but the outcomes were improved compared with previous national outcomes. The failings in record collection need to be rectified. This study provides baseline data for further development of cleft services within three regions.

The Cleft Audit Protocol for Speech—Augmented: A Validated and Reliable Measure for Auditing Cleft Speech

Objectives

To develop an assessment tool for use in intercenter audit studies of cleft speech and to test its acceptability, validity, and reliability. The tool is to be used systematically to record and report speech outcomes, providing an indication of treatment needs and continuing burden of care.

Setting

Regional Cleft Center, U.K.

Methods

The Cleft Audit Protocol for Speech—Augmented (CAPS-A) was developed by three cleft speech experts who identified the key features required from existing assessment measures. Criterion validity was assessed by comparing the Cleft Audit Protocol for Speech—Augmented outcomes reported for 20 cases with clinical assessment results and other investigations. Intra- and interrater reliability were tested following the training of specialist speech and language therapists who used the Cleft Audit Protocol for Speech—Augmented on two occasions to assess 10 cases. The raters evaluated acceptability and ease of using a questionnaire.

Results

The mean percentage agreement for criterion validity in each section was 87% (range 70% to 100%). Both intra- and interexaminer reliability were rated as good/very good (Kappa 0.61 to 1.00) for seven sections and moderate (Kappa 0.41 to 0.60) for three sections. Raters reported that the Cleft Audit Protocol for Speech—Augmented was acceptable and easy to use with appropriate training.

Conclusion

An acceptable, valid, and reliable cleft speech audit tool has been developed based on a small sample. The Cleft Audit Protocol for Speech—Augmented is recommended for use in intercenter audit studies in the U.K. and Ireland and could be used in other English-speaking countries. In addition, it has wider applicability for use in reporting speech outcomes of surgical procedures.

Use of a Perceptual Evaluation Instrument to Assess the Effects of Infant Orthopedics on the Speech of Toddlers with Cleft Lip and Palate

Objective

To investigate the effects of infant orthopedics (IO) administered in the first year of life on the speech characteristics of 2.5-year-old children with complete unilateral cleft lip and palate (UCLP) using a perceptual evaluation instrument with equal-appearing interval (EAI) scales.

Design

In a prospective randomized clinical trial (Dutchcleft), two groups of children with complete UCLP were followed longitudinally. One group received IO based on a modified Zurich approach (IO group), and the other group did not (non-IO group). The appliance was used until soft palate closure at age 12 months. Hard palate closure is delayed until 9 years of age.

Participants

Three groups of 2.5-year-old toddlers participated in this investigation: 10 IO, 10 non-IO, and 8 noncleft controls matched for age and socioeconomic status.

Method

Five trained listeners assessed the children's speech in a blinded perceptual rating procedure. They judged 13 specific speech characteristics and indicated their total impression of speech on EAI scales.

Results

The reliability and consistency of 11 of the rating scales was good. The intelligibility rating scale was the single speech characteristic that distinguished the IO group from the non-IO group; the IO group was judged to be superior. The cleft groups differed from the noncleft group on 9 of the 11 scales.

Conclusions

Evaluation of speech by means of the present newly developed perceptual rating instrument showed that the IO group obtained significantly higher ratings for intelligibility than the non-IO group. The groups did not differ regarding any of the other speech aspects.

Methodology for Perceptual Assessment of Speech in Patients with Cleft Palate: A Critical Review of the Literature

Objective and Design

This review of 88 articles in three international journals was undertaken for the purpose of investigating the methodology for perceptual speech assessment in patients with cleft palate. The articles were published between 1980 and 2000 in the Cleft Palate–Craniofacial Journal, the International Journal of Language and Communication Disorders, and Folia Phoniatrica et Logopaedica.

Results and Conclusions

The majority of articles (76) were published in the Cleft Palate–Craniofacial Journal, with an increase in articles during the 1990s and 2000. Information about measures or variables was clearly given in all articles. However, the review raises several major concerns regarding method for collection and documentation of data and method for measurement. The most distressing findings were the use of a cross-sectional design in studies of few patients with large age ranges and different types of clefts, the use of highly variable speech samples, and the lack of information about listeners and on reliability. It is hoped that ongoing national and international collaborative efforts to standardize procedures for collection and analysis of perceptual data will help to eliminate such concerns and thus make comparison of published results possible in the future.

Female and Male Differences in Academic Achievement in Individuals With Cleft: A Population-Based Register Study

OBJECTIVE

The focus of this study was to determine if there is any significant difference in academic achievement for girls and boys with a cleft compared to the general population of Swedish students at graduation from compulsory school.

DESIGN

A retrospective population-based study using data obtained from the Swedish Medical Birth Register that was linked to the Swedish School-Grade Register.

PARTICIPANTS

Two hundred seventy girls and 241 boys with cleft palate (CP), 222 girls and 429 boys with cleft lip (CL), and 299 girls and 531 boys with cleft lip and palate (CLP) were compared with the compulsory school population comprising 609,397 girls and 640,007 boys.

MAIN OUTCOME MEASURES

(1) Odds of receiving the lowest grade and reduced odds in receiving high grades in Mathematics, English, and Swedish. (2) grade point average (GPA).

RESULTS

In all 3 subject grades, for boys with cleft there was no difference when compared to the male population. Girls with cleft were similar to their peers with a few exceptions. Girls with CLP had lower Math grades, and girls with CP had lower Math, English, and Swedish grades. Girls with CP and CLP achieved a significantly lower GPA in comparison to the female population and boys with CP and CL achieved lower GPAs in comparison to the male population.

CONCLUSIONS

This study indicates that educational outcomes for girls with cleft are more negatively affected than for boys with cleft.

Comparing Methodologies in a Series of Speech Outcome Studies

Background:

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

Methodology:

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

Results:

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

Conclusion:

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

Closing the Loop on Centralization of Cleft Care in the United Kingdom

Objective:

We highlight a major study that investigated the impact of reconfigured cleft care in the United Kingdom some 15 years after centralization. We argue that centralization as an intervention has a major impact on outcomes.

Setting:

Audit clinics held in Cleft Centers in the United Kingdom.

Patients, Participants:

Five-year-olds born between April 1, 2005, and March 31, 2007, with nonsyndromic unilateral cleft lip and palate.

Interventions:

Centralization of cleft care.

Main Outcome Measure(s):

We collected routine clinical measures (speech recordings, hearing, photographs, models, oral health, psychosocial factors) in a very similar way to a previous survey.

Results:

We identified 359 eligible children and recruited 268 (74.7%) to the study. Overall, their outcomes were better post-centralization. There have been marked improvements in dentoalveolar arch relationships and in speech whereas the prevalence of dental caries and hearing loss are unchanged.

Conclusions:

Centralized cleft care has changed UK outcomes considerably and there is no argument for returning to a dispersed model of treatment.

A Standard Set of Outcome Measures for the Comprehensive Appraisal of Cleft Care

Care of the patient with cleft lip and/or palate remains complex. Prior attempts at aggregating data to study the effectiveness of specific interventions or overall treatment protocols have been hindered by a lack of data standards. There exists a critical need to better define the outcomes- particularly those that matter most to patients and their families-and to standardize the methods by which these outcomes will be measured. This report summarizes the recommendations of an international, multidisciplinary working group with regard to which outcomes a typical cleft team could track, how those outcomes could be measured and recorded, and what strategies may be employed to sustainably implement a system for prospective data collection. It is only by agreeing on a common, standard set of outcome measures for the comprehensive appraisal of cleft care that intercenter comparisons can become possible. This is important for quality-improvement endeavors, comparative effectiveness research, and value-based health-care reform.

The Effects of Enhanced Milieu Teaching With Phonological Emphasis on the Speech and Language Skills of Young Children With Cleft Palate: A Pilot Study

PURPOSE

The purpose of this pilot study was to investigate the extent to which a naturalistic communication intervention, enhanced milieu teaching with phonological emphasis (EMT+ PE), improved the language and speech outcomes of toddlers with cleft lip and/or palate (CL/P).

METHOD

Nineteen children between 15 and 36 months (M = 25 months) with nonsyndromic CL/P and typical cognitive development were randomly assigned to a treatment (EMT+PE) or nontreatment, business-as-usual (BAU), experimental condition. Participants in the treatment group received forty-eight 30-min sessions, biweekly during a 6-month period. Treatment was delivered in a university clinic by trained speech language pathologists; fidelity of treatment was high across participants.

RESULTS

Children in the treatment group had significantly better receptive language scores and a larger percentage of consonants correct than children in the BAU group at the end of intervention. Children in the treatment group made greater gains than children in the BAU group on most language measures; however, only receptive language, expressive vocabulary (per parent report), and consonants correct were significant.

CONCLUSIONS

The results of this preliminary study indicate that EMT+PE is a promising early intervention for young children with CL/P. Replication with a larger sample and long-term follow-up measures are needed.

Speech in 10-Year-Olds Born with Cleft Lip and Palate: What Do Peers Say?

Objective

The aim of this study was to explore how 10-year-olds describe speech and communicative participation in children born with unilateral cleft lip and palate in their own words, whether they perceive signs of velopharyngeal insufficiency (VPI) and articulation errors of different degrees, and if so, which terminology they use.

Methods/Participants

Nineteen 10-year-olds participated in three focus group interviews where they listened to 10 to 12 speech samples with different types of cleft speech characteristics assessed by speech and language pathologists (SLPs) and described what they heard. The interviews were transcribed and analyzed with qualitative content analysis.

Results

The analysis resulted in three interlinked categories encompassing different aspects of speech, personality, and social implications: descriptions of speech, thoughts on causes and consequences, and emotional reactions and associations. Each category contains four subcategories exemplified with quotes from the children's statements. More pronounced signs of VPI were perceived but referred to in terms relevant to 10-year-olds. Articulatory difficulties, even minor ones, were noted. Peers reflected on the risk to teasing and bullying and on how children with impaired speech might experience their situation. The SLPs and peers did not agree on minor signs of VPI, but they were unanimous in their analysis of clinically normal and more severely impaired speech.

Conclusions

Articulatory impairments may be more important to treat than minor signs of VPI based on what peers say.

Five-year speech and language outcomes in children with cleft lip-palate

OBJECTIVE

To investigate 5-year speech and language outcomes in children with cleft lip/palate (CLP).

MATERIALS AND METHODS

Thirty-eight children aged 4-7 years and 8 months were recruited for this study. Speech abilities including articulation, resonance, voice, and intelligibility were assessed based on Thai Universal Parameters of Speech Outcomes. Language ability was assessed by the Language Screening Test.

RESULTS

The findings revealed that children with clefts had speech and language delay, abnormal understandability, resonance abnormality, and voice disturbance; articulation defects that were 8.33 (1.75, 22.47), 50.00 (32.92, 67.08), 36.11 (20.82, 53.78), 30.56 (16.35, 48.11), and 94.44 (81.34, 99.32).

CONCLUSIONS

Articulation errors were the most common speech and language defects in children with clefts, followed by abnormal understandability, resonance abnormality, and voice disturbance. These results should be of critical concern. Protocol reviewing and early intervention programs are needed for improved speech outcomes.

Prevalence of Voice Disturbances in the Pediatric Craniofacial Patient Population

Objective

To report on the prevalence of voice disturbances in the pediatric craniofacial population and to prove that the pediatric Voice Handicap Index (pVHI) is a useful questionnaire for this unique population.

Study Design

Case series with chart review.

Setting

Tertiary care center.

Subjects

Pediatric patients seen by a pediatric otolaryngologist in a craniofacial clinic.

Methods

Consecutive patients (N = 366) seen by a single pediatric otolaryngologist in a craniofacial clinic from July 2011 to September 2012 were included. Any patient specifically referred for airway problems or voice difficulties completed a pVHI questionnaire. Patients each underwent an evaluation including flexible fiberoptic laryngoscopy and videostroboscopy. Voice disturbance was further characterized into dysphonia, hypernasality, or hyponasality.

Results

Of all the patients evaluated, 280 (77%) were specifically referred for airway problems or voice disturbance. Of those referred, 39 (10.7%) were found to have an organic vocal fold pathology causing dysphonia, as seen on the videostroboscopic examination; 53.7% of these lesions were attributable to potential iatrogenic causes. Hypernasality and hyponasality were seen in 116 (31.7%) and 78 (21.3%) patients, respectively. The pVHI was 3.95, 26.3, 11.34, and 10.53 for those with no voice disturbance, dysphonia, hypernasality, and hyponasality, respectively.

Conclusion

Pediatric patients with craniofacial disorders have a higher prevalence of dysphonia than the general pediatric population. The majority of causes of dysphonia in these patients are possibly iatrogenic in origin. The pVHI serves as a useful questionnaire in this unique patient cohort to quantify the disability from not only dysphonia but also hypernasality and hyponasality.

The Americleft Speech Project: A Training and Reliability Study

OBJECTIVE

To describe the results of two reliability studies and to assess the effect of training on interrater reliability scores.

DESIGN

The first study (1) examined interrater and intrarater reliability scores (weighted and unweighted kappas) and (2) compared interrater reliability scores before and after training on the use of the Cleft Audit Protocol for Speech-Augmented (CAPS-A) with British English-speaking children. The second study examined interrater and intrarater reliability on a modified version of the CAPS-A (CAPS-A Americleft Modification) with American and Canadian English-speaking children. Finally, comparisons were made between the interrater and intrarater reliability scores obtained for Study 1 and Study 2.

PARTICIPANTS

The participants were speech-language pathologists from the Americleft Speech Project.

RESULTS

In Study 1, interrater reliability scores improved for 6 of the 13 parameters following training on the CAPS-A protocol. Comparison of the reliability results for the two studies indicated lower scores for Study 2 compared with Study 1. However, this appeared to be an artifact of the kappa statistic that occurred due to insufficient variability in the reliability samples for Study 2. When percent agreement scores were also calculated, the ratings appeared similar across Study 1 and Study 2.

CONCLUSION

The findings of this study suggested that improvements in interrater reliability could be obtained following a program of systematic training. However, improvements were not uniform across all parameters. Acceptable levels of reliability were achieved for those parameters most important for evaluation of velopharyngeal function.

The Cleft Care UK study. Part 4: perceptual speech outcomes

OBJECTIVES

To describe the perceptual speech outcomes from the Cleft Care UK (CCUK) study and compare them to the 1998 Clinical Standards Advisory Group (CSAG) audit.

SETTING AND SAMPLE POPULATION

A cross-sectional study of 248 children born with complete unilateral cleft lip and palate, between 1 April 2005 and 31 March 2007 who underwent speech assessment.

MATERIALS AND METHODS

Centre-based specialist speech and language therapists (SLT) took speech audio-video recordings according to nationally agreed guidelines. Two independent listeners undertook the perceptual analysis using the CAPS-A Audit tool. Intra- and inter-rater reliability were tested.

RESULTS

For each speech parameter of intelligibility/distinctiveness, hypernasality, palatal/palatalization, backed to velar/uvular, glottal, weak and nasalized consonants, and nasal realizations, there was strong evidence that speech outcomes were better in the CCUK children compared to CSAG children. The parameters which did not show improvement were nasal emission, nasal turbulence, hyponasality and lateral/lateralization.

CONCLUSION

These results suggest that centralization of cleft care into high volume centres has resulted in improvements in UK speech outcomes in five-year-olds with unilateral cleft lip and palate. This may be associated with the development of a specialized workforce. Nevertheless, there still remains a group of children with significant difficulties at school entry.

Progressive Tightening of the Levator Veli Palatini Muscle Improves Velopharyngeal Dysfunction in Early Outcomes of Primary Palatoplasty

BACKGROUND

Management of the levator veli palatini with intravelar veloplasty has been shown to improve speech resonance. The senior author has introduced a more aggressive procedure where the levator is separately dissected, overlapped, and tightened. This study compares resonance results from four levator management protocols: non-intravelar veloplasty, Kriens intravelar veloplasty, radical intravelar veloplasty, and overlapping intravelar veloplasty.

METHODS

Retrospective chart review was conducted on 252 patients who underwent primary palatoplasty with speech follow-up at 3 years of age. Velopharyngeal function was evaluated with perceptual speech examinations, and subjects were scored on a four-point scale (0 = normal resonance; 1 = occasional hypernasality/nasal emission/turbulence/grimacing, no further assessment warranted; 2 = mild hypernasality/intermittent nasal turbulence/grimacing, velopharyngeal imaging suggested; and 3 = severe hypernasality, surgical intervention recommended). Fisher's exact test was used to compare outcomes.

RESULTS

A single surgeon performed all the non-intravelar veloplasty (n = 92), Kriens intravelar veloplasty (n = 103), and radical intravelar veloplasty (n = 31), whereas the senior author performed the overlapping intravelar veloplasty (n = 26). Cleft severity proportions were equivalent across the four methods (p = 0.28). Patients who underwent overlapping intravelar veloplasty demonstrated significantly better velopharyngeal function, and none required further imaging or secondary surgery compared with the other three procedures (p < 0.001).

CONCLUSIONS

Speech resonance outcomes at 3 years of age are improved and need for secondary velopharyngeal dysfunction management is reduced with more aggressive levator dissection and reconstruction during primary one-stage palatoplasty. Results were best when the muscle was overlapped.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, III.