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.

Perceptions of Audible Nasal Emission in Speakers with Cleft Palate: A Comparative Study of Listener Judgments

Objective

Audible nasal emission is a common speech distortion observed in persons with cleft palate. This study examined the validity and reliability of perceptual judgments of audible nasal emission using interval scaling and magnitude estimation techniques.

Participants

Speech samples were collected from six adolescents with repaired cleft palate, all of whom demonstrated audible nasal emission. A total of 31 adults performed rating tasks in which they judged the severity of audible nasal emission in speech samples.

Measures

Occurrences of audible nasal emission in speech samples were identified using visual and auditory inspection. Using an acoustic modification technique, samples were digitally modified to amplify perceived occurrences of audible nasal emission to create three stimulus conditions. The original recording of the speech samples served as a control condition. The severity of audible nasal emission in the samples was judged by multiple listeners using interval scaling and magnitude estimation without a modulus. Statistical analysis included analysis of variance, regression, and curve-fitting methods.

Results

Magnitude-estimation ratings demonstrated stronger evidence of validity and reliability than interval scaling. A curvilinear relationship was found between the sets of ratings.

Conclusions

The results of this study suggest that audible nasal emission may be a prothetic or ratio-level perceptual continua. Listeners should consider using magnitude estimation or other ratio-based methods for perceptual judgments of audible nasal emission.

Structural and functional causes of hypernasality in velocardiofacial syndrome. A pilot study

OBJECTIVE

Hypernasality in velocardiofacial syndrome (VCFS) is more severe, persistent, and difficult to manage compared to other populations with cleft palate or velopharyngeal (VP) dysfunction. This pilot study investigated why children with VCFS have more severe hypernasality.

METHODS

Pressure-flow methodology indirectly measured VP orifice size and VP closure timing during speech in a group of 5 children with VCFS, 5 children with cleft palate, and 6 normal children.

RESULTS

Children with VCFS demonstrated significant differences in VP closure timing and hypernasality. There were no significant group differences in VP orifice size. Duration of nasal airflow was the strongest predictor of judgments of hypernasality.

CONCLUSION

This study provides preliminary evidence that VP closure timing may account for the more severe hypernasality in children with VCFS, compared to structural factors alone.

Permanent tooth development in children with cleft lip and palate

PURPOSE

The purposes of this study were to: (1) quantify and compare permanent tooth development of cleft lip and palate (CLP) patients to age- and gender-matched controls; (2) relate these findings to cleft type and severity; and (3) examine delays in individual permanent maxillary teeth related to their proximity to the cleft.

METHODS

Standardized methods using panoramic radiographs were employed to stage dental development and dental age for 49 children with clefts and 49 matched controls. Data were analyzed with a mixed linear model.

RESULTS

Analyses indicated a correlation between delayed permanent tooth development and CLP with an overall delay of 0.52 years (P = .02) and with boys accounting for all the delay. No differences were found between subjects with unilateral or bilateral clefts. A nonsignificant trend was noted for greater delay in subjects with clefts of the primary and secondary palates vs primary palate alone. Teeth most often affected by the delay were maxillary first and second premolars and maxillary second molars.

CONCLUSIONS

While permanent tooth development is delayed in cleft lip and palate patients, this delay is: found in boys only; is independent of the cleft type and severity; and is not correlated with proximity to the cleft.

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

OBJECTIVE

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

DESIGN

Cross-sectional group experimental design.

PARTICIPANTS

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

METHODS AND MEASURES

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

RESULTS

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

CONCLUSIONS

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

The presurgical status of the alveolar cleft and success of secondary bone grafting

OBJECTIVE

The primary purpose of this study was to evaluate presurgical status of the alveolar cleft site and success of secondary alveolar bone grafting.

DESIGN

Thirty patient records were retrospectively reviewed. Patients selected for inclusion had isolated cleft of at least the primary palate. Patients with additional anomalies were not selected. The study population consisted of 15 female sites and 16 male cleft sites. There were two bilateral cleft lip and palate (CLP) patients and 28 unilateral CLP patients. The age at the time of the secondary alveolar bone grafting ranged from 7 years to 14 years, 4 months.

SETTING

The study was conducted at the Cleft Palate Clinic at the University of Minnesota, School of Dentistry.

METHOD

Presurgical radiographs taken at least 1 month prior to the secondary bone grafting and postsurgical radiographs taken at least 6 months after bone surgery were measured. Measurements included size of the cleft defect and bone support for distal and mesial teeth adjacent to the cleft. Evaluation of success was determined on the basis of postsurgical measurements of satisfactory, intermediate, and unsatisfactory outcomes.

RESULTS AND CONCLUSION

The size of the cleft defect was not correlated with the success rate of the secondary alveolar bone grafting. If the amount of distal bone support for the mesial tooth was the same as those in a periodontally healthy individual, a satisfactory outcome was 5.8 times more likely. If the amount of mesial bone support for the distal tooth was the same as those in a periodontally healthy individual, the satisfactory outcome was 3.8 times more likely. Although not a primary purpose of the study, it was found that in this study population, if the patient was female, a satisfactory outcome was 3.8 times more likely.

Acquisition of linguistic and cognitive skills by children with cleft palate

This study compared the early cognitive and linguistic development of young children with cleft palate (N = 28) to that of noncleft children (N = 29). Measures included the Mental scale of the Bayley Scales of Infant Development, the Minnesota Child Development Inventory, Mean Length of Utterance, and words acquired by 24 months. Children with cleft palate, although well within the normal range, performed significantly below the children in the control group on the Mental Scale of the Bayley Scales of Infant Development, some subscales of the Minnesota Child Development Inventory, and words acquired by 24 months. Differences observed in the cognitive development of children with and without cleft palate were verbal as opposed to nonverbal (i.e., linguistic in nature) and were related to hearing status at 12 months and velopharyngeal adequacy.

Comparison of the hearing histories of children with and without cleft palate

Aggressive otologic management has been recommended for children with cleft palate because of the almost universal occurrence of otitis media with effusion (OME) in these children and the association of OME with hearing loss and possible language, cognitive, and academic delays. In this study, 28 children with cleft palate and 29 noncleft children were seen at 3-month intervals from 9 to 30 months to compare otologic treatment and management. Hearing and middle ear function were tested at each session; information on ventilation tube placement was obtained from medical records. Ventilation tubes were placed earlier and more often in children with cleft palate, but children with cleft palates failed the hearing screening more often. The correlation between age at first tube placement and frequency of hearing screening failures was significant for the children with cleft palate, indicating that the later tubes were first placed, the poorer the child's hearing.

Speech ratings by speech clinicians, parents and children

Ratings of speech samples of children with cleft palate were obtained from speech clinicians in a Cleft Palate Clinic, speech clinicians in the public schools, parents of children with clefts, parents of children without clefts, children with clefts and children without clefts. Analyses of the obtained ratings suggest that nasality and articulation ratings obtained from adult groups do not differ appreciably. Correlations between ratings of nasality and articulation are interpreted as suggesting that speech clinicians are more likely to differentiate between these two variables than other listener groups.

The effects of listening conditions on speech rating obtained in a clinical setting

The effects of listening conditions on speech ratings from trained listeners were assessed in a clinical setting. The listening conditions were: (1) while face-to-face with the patient; (2) while observing the patient through a mirror and listening via a sound system; and (3) while listening to a tape recording of the patient. Analysis of 100 patients rated under each listening condition revealed no significant condition effects for resonance and articulation judgments. Voice ratings in the face-to-face condition were different from those made in the other conditions.

The modification of velar movement

The use of displacement transducers and certain procedures for training in an initial attempt to increase soft palate movement in a person with velopharyngeal inadequacy is described. An intraoral appliance with associated instrumentation for monitoring velar movement during speech is also described. Systematic training procedures using the visual feedback of velar movement offered by the transducer appliance were carried out over a period of approximately three months. Baseline elevation and elevation under visual feedback only were determined initially. Conditioning sessions followed during which the subject received points or reinforcement each time he achieved a predetermined criterion of velar elevation. Radiographs were taken before and after the study. Velar elevation was modified, but other structural changes negated any changes in velopharyngeal gap or the perceptual characteristics of speech. Problems encountered in instrumentation and procedure are reported.

Oligodontia, taurodontia, and sparse hair growth--a syndrome

That the speech clinician can play an important role in the identification and referral of clients with certain syndromes is exemplified in this case report. Speech and structural deviations in a client seen in the Osseo, Minnesota, Public Schools prompted referral to the University of Minnesota School of Dentistry. Although the structural deviations were of minimal significance for speech production, the combination of physical findings led to the diagnosis of a rare syndrome of oligodontia, taurodontism, and facial features of ectodermal dysplasia. The dental and genetic significance of these findings are discussed.