Unrepaired clefts in the hard palate: speech deficits at the ages of 5 and 7 years and their relationship to size of the cleft.

The purpose of the study was to investigate the relationship between the size of oronasal openings in the hard palate and speech deficits. Audiotape recordings and plaster casts were taken according to standard procedures at 5 and 7 years of age from 22 consecutive children born with complete unilateral cleft lip and palate treated at Sahlgrenska University Hospital, G?teborg, Sweden. The soft palate had been repaired before the age of 12 months, whereas the cleft in the hard palate was left unrepaired, to be closed later. Perceptual judgements of nine speech variables at 5 and 7 years of age were correlated with measures of the area of the residual cleft in the hard palate. "Retracted oral articulation" (to velar place) found in nine of the 22 children correlated significantly with the area of the cleft at the age of 5 years but not later. The establishment of this particular speech error seems to be related to the size of an oronasal opening.     

Cleft lip and palate patients prior to delayed closure of the hard palate: evaluation of maxillary morphology and the effect of early stimulation on pre-school speech

Speech and maxillary development were analysed in two groups of patients with unilateral cleft lip and palate; both groups had early jaw orthopaedic treatment and a surgical regimen that included two-stage lip surgery (mean ages of 2 and 19 months) and soft palate repair (8 months). Closure of the hard palate was postponed until the children were 8 to 10 years of age. The first group comprised 10 consecutive patients who were analysed at 5 and 7 years of age, and the second group seven patients who were studied at the age of 5. Both groups were thus investigated before the repair of the cleft in the hard palate. In addition to surgical and jaw orthopaedic treatment, the second group of patients received early stimulation of lip and tongue tip movements. Our results indicated that hypernasality was less a problem than was retracted palatal or velar articulation of dental consonants. These deviations tended to be reduced, however, after early stimulation. There seemed to be no clear association between the size of the residual cleft in the hard palate and the extent of speech development. The average size of the residual cleft in our patients was comparatively small, and decreased further during follow up. We conclude that preschool children with unilateral cleft lip and palate may develop good speech, in spite of the residual cleft, if they use an intraoral plate and are given extra lip and tongue tip stimulation, together with early speech therapy if necessary.     

Speech development in patients with unilateral cleft lip and palate treated with different delays in closure of the hard palate after early velar repair: a longitudinal perspective.

We wanted to find out if different timing of delayed repair of the hard palate in a two-stage procedure had an impact on the speech of 26 patients with unilateral cleft lip and palate (UCLP). The soft palate was closed at the age of 7 months and the hard palate between 38 and 89 months of age. Speech audio recordings at the age of 3 years (baseline, before any repair of the hard palate) and at the ages of 5, 7, and 10 years (the latter obtained at least one year after closure) were analysed. We used standardised speech assessments at routine follow-up and assessment by one external listener. The prevalence of speech errors caused by the cleft was similar to those described in previous reports from our centre in which hard palate repair was delayed. Unexpectedly, the results showed no difference in speech production related to timing of hard palate repair, except for nasal air leakage at the age of 7 years.     

腭裂术后语音清晰度影响因素的分析研究

目的：研究影响腭裂术后患者语音清晰度的相关因素。方法：２９名腭裂修复术后均未行语音训练的复查患者分成语音缺陷组（ＩＡｒ）和语音清晰组（ＮＡｒ）,进行病 列回顾性研究及问卷调查。结果：两组患者的年龄及裂型构成无差异：ＩＡｒ组比ＮＡｒ组列多生活在农村地区,父母文化水平偏低,且较少受到发音纠正,两组均有显著性差异（Ｐ〈０．００５）。结论：腭裂度对术后语音清晰度无明显影响。家庭文化背景及父母对患儿的发音纠正是影响腭裂患者术后语音清晰度的重要因素。     

先天性唇、腭裂对患儿呼吸系统顺应性的影响

目的 探讨先天性辰、腭裂对患儿呼吸系统顺应性（ＣＴ）的影响。方法 唇裂或腭裂病儿２４０例（观察组）,非唇腭裂病儿６０例（对照组）均为择期手术患,按年龄段：１～１２月、１～３岁、４～７岁、８～１２岁,各分为５个亚组。全麻诱导气管内插管后,行机械通气,保持ＰＥＴＣＯ２４～４．６ｋＰａ,用Ｄａｔｅｘ Ｕｌｔｉｍａ监测仪测定ＣＴ。结果 与非唇裂同一年龄组ＣＴ值相比,唇裂各年龄组、腭裂１～１２月及１～３岁组     

兰氏和双反Z法腭裂修复术后患儿语音清晰度对比

目的比较兰氏和双反Z法腭裂修复术后患儿的语音清晰度,寻找重建腭咽闭合的最佳手术方法。方法选取2009年至2013年在我院口腔颌面外科就诊的先天性软腭裂患儿69例,其中行双反Z法腭裂修复术35例(双反Z法组),行兰氏法腭裂修复术34例(兰氏法组)。患儿3.5岁后随访,由3名语音师进行单盲性审听,比较两组患儿术后语音清晰度。结果语音测评结果显示,双反Z法组患儿术后患者语音清晰度平均达到88.72%±6.05%,明显高于兰氏法组的71.31%±3.46%,语音改善明显。结论双反Z法能够充分缩小咽腔、延长软腭,重建软腭肌肉结构,更有利于恢复良好的腭咽闭合功能。     

Speech Outcome after Cleft Palate Surgery with the G teborg Regimen Including Delayed Hard Palate Closure

The regimen for treatment of children with cleft lip and palate in Göteborg, Sweden, until 1996 included early soft palate repair at 6-8 months of age and delayed closure of the hard palate at about 8 years of age to improve maxillary growth. The aims of this report were to describe the treatment concept and to present speech data of 59 children treated by this method. The speech of 38 children with unilateral and 21 with bilateral cleft lip and palate was evaluated perceptually from standardised tape recordings of repeated sentences and spontaneous speech at five ages from 3 to 16 years of age. All patients were not evaluated at each age level. The results showed a low prevalence of hypernasality after hard palate closure and pharyngeal flap surgery in only five children (8%), indicating a primary velopharyngeal insufficiency in less than 10% of the children. Only three children with bilateral clefts had glottal articulation when at pre-school age and no child with a unilateral cleft did. These results were interpreted as an indication of velopharyngeal competence (VPC) in most of the children. In addition, the speech problem found in these children consisted of retracted oral articulation of alveo-dental pressure plosives, which is almost always an indicator of VPC. However, we do consider that retracted oral articulation is a problem and to improve our results further we have decided to modify the technique for soft palate closure slightly and place the vomer flap further anteriorly to encourage narrowing of the cleft in the hard palate, and to close the hard palate at 3 years of age.     

骨缝牵引成骨修复腭裂的临床初步研究

目的 临床探索骨缝牵引成骨修复腭裂的新技术。方法 选择2～4岁的腭裂患儿。一期手术在全麻下安置腭裂牵引器，牵引腭骨向中线和向后移动；牵引期持续约4～5个月。裂隙合拢后进行二期手术，修复裂隙。用误差为0．2％的游标卡尺，测量牵引前和牵引后上颌牙弓宽度、裂隙宽度和硬腭长度。结果 临床应用8例。2例因牵引器在安置后l周内脱落而终止牵引。6例经不同时间的牵引后，裂隙缩小，裂隙两侧的组织显著延长。其中牵引时间最长为126d，最短为37d；裂隙宽度平均缩小6．5mm；硬腭长度平均延长4．8mm。结论 临床证实了骨缝牵引具有诱导腭部组织再生、关闭或缩小裂隙和延长硬腭的可能性。     

Correlation between the age at repair and speech outcome in patients with isolated cleft palate.

The effect of the age at primary palatal repair on the speech of 3-year old children with isolated cleft palate was assessed. The group comprised 108 consecutive children whose palates were repaired at the mean ages of 12.9 (n = 45), 18.5 (n = 18) and 22.1 months (n = 45). Signs of cleft palate speech and the degree of speech impairment were recorded. The signs sought were: hypernasality, audible nasal air emission, and misarticulations associated with velopharyngeal insufficiency. The speech impairments were subdivided into three categories by combining the signs of cleft palate speech. The results showed that children who were operated on at the age of about 12-18 months were significantly better speakers than those operated on later. Of these 46 were rated as normal or practically normal speakers (73%), compared with 10 of the children who had their repairs delayed until about 22 months (22%). As a result of the speech evaluations, it was predicted that 5 (11%), 0 and 21 (47%) children in the early, middle, and late closure groups, respectively, required secondary surgery to eliminate signs of cleft palate speech associated with velopharyngeal inadequacy. The numbers who had secondary surgery were 4, 0 and 18 in the three groups.     

Speech outcomes at 5 and 10 years of age after one-stage palatal repair with muscle reconstruction in children born with isolated cleft palate

Background: The aim of this study was to investigate speech outcomes in children with clefts in the hard and/or soft palate only (CPH/CPS), in order to determine the prevalence of cleft speech characteristics, the change between 5 and 10?years of age, and the difference in occurrence between CPH and CPS.

Methods: A consecutive series of 88 children born with CPH or CPS were included in a retrospective cohort. All participants were treated with one-stage palatal repair using a minimal incision technique with muscle reconstruction (mean age 13?months). Twelve children (14%) received a velopharyngeal flap. Cleft speech variables were rated at 5 and 10?years of age independently by three experienced external speech-language pathologists. Inter- and intra-rater agreements were determined, and the prevalence of cleft speech characteristics was calculated.

Results: Moderate-to-severe hypernasality and weak pressure consonants were present in 5%–10% of the children at 5?years, with marginal but statistically significant improvement at 10?years of age. Frequently or always occurring audible nasal air leakage was detected in 20% of children at age 5, and increased to ～35% of the children at 10?years. Ten per cent had compensatory articulation at age 5, and 25% demonstrated s-distortions, whereas few had these problems at age 10.

Conclusions: The results demonstrate low occurrence of compensatory articulation problems in this cohort, even by 5?years of age. The high presence of symptoms of velopharyngeal insufficiency at 10?years of age suggests a need for additional secondary velopharyngeal surgery.     

Palatal fistulas after primary repair of clefts of the secondary palate

Our aim was to assess whether severity of cleft, age at the time of repair, and the operating surgeon's experience contributed to the development of fistulas in patients with clefts of the secondary palate. We studied 814 children born between 1960 and 1999 with clefts of the secondary palate who had had their primary operation at the Department of Plastic Surgery, Rikshospitalet University Hospital, Oslo, Norway. Data were collected retrospectively from the archives of the Oslo Cleft Team. Palatal fistulas developed in 36 patients (4%), among whom 17 patients required correction (2% of the total). The incidence of fistulas was not related to sex. Patients with clefts of the hard and soft palate developed fistulas more often than patients with clefts of the soft palate only (8% compared with 1%, p<0.001). Patients with submucous cleft palates developed fistulas significantly more often than patients with clefts of the soft palate only (5% compared with 1%, p=0.02). Among patients with clefts of the hard and soft palate, the incidence of fistulas increased significantly with increasing age at the time of palatal closure (p=0.005). The incidence decreased significantly the more experienced the operating surgeon was for treating clefts of the hard and soft palate (p<0.001) but not for submucous clefts. Among patients with clefts of the hard and soft palate who had the palate closed at 14 months of age or later, the incidence of fistulas decreased from 21% when the operating surgeon had little experience to 0 when the surgeon had much experience. The incidence of fistulas was related to severity of cleft, age at palatal closure, and the operating surgeon's experience.     

Bilateral cleft lip and palate: experience from a center with a multidisciplinary approach

The aim of this work is to analyse the global experience of a center where a pluridisciplinar approach of the child affected with a cleft lip and palate is regularly done. Since january 1980 until january 2000, a total of 36 children (8 F, 28 M) with bilateral cleft lip and palate were treated. Only 5 children were born at this hospital. The others (n = 31) were referred soon after birth (24/31) or later for treat sequels. A multidisciplinary team evaluated every case. The parameters analysed were: surgical protocol, aesthetic and speech outcome, hearing disturbance, complications and the number of secondary lip surgeries. Surgical approach consisted on a soft palate closure before 3 months follow by a bilateral cheiloplasty (6 months) and a hard palate closure before 4 years of age, in the majority of cases (24/36). The esthetical result was evaluated in 25 children and was acceptable in the great majority (22/25). 16 children were submitted to tympanic draining in order to treat their secretory otitis. Speech outcome was analysed in 27 children and was good in 23. With a follow-up of 8.4 years, 15 children (8 treated soon on this center and 7 that came for their sequels) were treated for complications. There was a media of 4.5 surgeries per children.     

Maxillary dental arch and occlusion in patients with unilateral cleft lip and palate treated with different delays in closure of the hard palate after early velar repair.

We wanted to find out if growth of the maxilla in 26 patients with unilateral cleft lip and palate (UCLP) was adversely affected by having the residual cleft of the hard palate repaired earlier than had been done previously in a 2-stage palatal closure protocol. The ages at repair of the hard palate of the present patients ranged from 38 to 89 months. Dental casts from ages about 3 years (before any repair of the hard palate), 5, 7, and 10 years of age were analysed. The results indicated that earlier repair of the cleft in the hard palate did not influence maxillary growth differently from the later repair.     

Islandized mucoperiosteal flaps: A versatile technique for closure of a wide palatal cleft

BACKGROUND:

A variety of surgical methods have been described to repair wide cleft palate; they are all challenging to perform and yield consistently good results. The islandized mucoperiosteal flap, the technique described in the present article, is very versatile because it can close palatal defects of any size without undue tension. Moreover, it provides adequate length and mobility of the soft palate with improved speech and feeding functions without fistula formation.

METHODS:

Between 2005 and 2011, 36 patients with wide cleft palate were operated on using islandized mucoperiosteal flaps. This technique involves dissection of the neurovascular bundle from the mucoperiosteal flaps for approximately 1 cm and dissecting the muscle from the posterior edge of the hard palate with intravelar veloplasty. The flaps subsequently become freely mobile in all directions. It can move medially to close palatal defects of any size without tension. In addition, posterior or backward mobilization lengthens the soft palate and renders it freely mobile.

RESULTS:

All repairs were successful, with no complications and no patients requiring secondary procedures. All patients regained normal feeding function three weeks postoperatively. All patients showed normal nasal resonance of speech except for two (three and five years of age) who experienced abnormal resonance in the form of open nasality that required regular speech therapy for six months. There was significant improvement and no secondary procedures were required for either.

CONCLUSIONS:

A technical modification for closure of wide palatal clefts is introduced. The islandized mucoperiosteal flap, which is a very versatile technique, can close cleft palates of any width without tension, lengthens the soft palate and renders it freely mobile for proper speech functions. Using this technique, good speech and feeding function with no complications were achieved.     

腭裂患儿中耳功能的评价

对56例腭裂患儿和50例正常儿童的中耳功能进行对比评价。年龄5～14岁。均进行耳科常规及声阻抗检查,发现腭裂患儿中耳静态压力与声顺值,声镫骨肌反射引出率都低于正常儿童。其咽鼓管功能不良,调节中耳压力的能力差,通过吞咽来主动开放咽鼓管的功能受限,故腭裂患儿的合理治疗需要多科医生的共同配合。     

The effect of form and dimension on the management of the maxillary arch in unilateral cleft lip and palate conditions

Over the past 28 years, a series of studies at the West Midlands Regional Plastic Unit has compared the maxillary arches at birth and 4 months of 30 normal children and two groups of children with unilateral cleft lip and palate, one of which had presurgical maxillary orthopaedic treatment and the other which did not. Other studies have compared the area of palatal mucosa at birth with the overall size of the arch at 5 years of age and have also assessed the long term effect of simultaneous lip and palate repair and presurgical treatment on the profile, occlusion and speech of the older patient. The paper summarises the findings of the investigations and considers how they have contributed to an understanding of the unilateral cleft lip and palate problem particularly with regard to the long term management of such cases and the provision of a suitable treatment protocol.     

腭裂患儿中耳功能的评价

对５６例腭裂患儿和５０例正常儿童的中耳功能进行对比评价。年龄５～１４岁。均进行耳科常规及声阻抗检查，发现腭裂患儿中耳静态压力与声顺值，声镫骨肌反射引出率都低于正常儿童。其咽鼓管功能不良，调节中耳压力的能力差，通过吞咽来主动开放咽鼓管的功能受限，故腭裂患儿的合理治疗需要多科医生的共同配合。     

早期修复腭裂的单侧手术

目的探讨一种治疗腭裂的新方法。方法本法对传统方法作了六项改进世。手术时,在腭部的一侧作完改变的六项操作以后,手术侧的腭部即彻底松弛,可以充分后退,增加该侧腭部先天不足的长度,并随意向近中侧移动,与对侧的裂缘接触,不需要在对侧再作同样的手术操作,即可将裂隙缝合。结果共用本法修复单侧和双侧腭裂151例,患者年龄4个月至5岁。手术后,无一例死亡,亦无一例复裂。年龄很小,尚未开始说话的婴幼儿患者,经本法修复腭裂以后,其语言的质量和发音的准确度都与同龄正常儿童无异。结论单侧手术的手术创伤、手术失血和手术时间都较同时在腭部两侧施行手术的传统方法更小、更少和更短。它是早期修复腭裂的一个较为安全的方法。     

Speech prognosis and need of pharyngeal flap for non syndromic vs syndromic Pierre Robin Sequence

Background

The aim of this retrospective study was to evaluate speech outcome and need of a pharyngeal flap in children born with nonsyndromic Pierre Robin Sequence (nsPRS) vs syndromic Pierre Robin Sequence (sPRS).

Methods

Pierre Robin Sequence was diagnosed when the triad microretrognathia, glossoptosis, and cleft palate were present. Children were classified at birth in 3 categories depending on respiratory and feeding problems. The Borel-Maisonny classification was used to score the velopharyngeal insufficiency.

Results

The study was based on 38 children followed from 1985 to 2006. For the 25 nsPRS, 9 (36%) pharyngeal flaps were performed with improvements of the phonatory score in the 3 categories. For the 13 sPRS, 3 (23%) pharyngeal flaps were performed with an improvement of the phonatory scores in the 3 children. There was no statistical difference between the nsPRS and sPRS groups (P = .3) even if we compared the children in the 3 categories (P = .2).

Conclusions

Children born with nsPRS did not have a better prognosis of speech outcome than children born with sPRS. Respiratory and feeding problems at birth did not seem to be correlated with speech outcome. This is important when informing parents on the prognosis of long-term therapy.     

Results of two-flap palatoplasty with regard to speech production

Summary Forty-five children with unilateral cleft lip and palate, who underwent two-flap palatoplasty as described by Bardach [6], were examined primarily for speech patterns using a previously designed protocol. Results indicated that in 80% of patients, velopharyngeal function was within normal limits. However, more than half (62%) needed further dental treatment or speech therapy (51%) before normal speech production could be expected. These findings indicate that the two-flap method is highly satisfactory as a technique for primary palatoplasty.This study was supported in part by PHS Program-Project Grants DE-00853 and DE-08537, The National Institute for Dental Research