Nasal airflow patterns during the velopharyngeal closing phase in speech in children with and without cleft palate.

OBJECTIVES: (1) To study the nasal airflow patterns during the velopharyngeal closing phase in speech produced by children with and without cleft palate. (2) To compare the nasal airflow patterns in bilabial, dental, and velar articulation in these children. DESIGN: Prospective, cross-sectional study of a consecutive series of children with cleft palate referred for routine speech evaluation and controls. SETTING: Sahlgrenska University Hospital, G?teborg, Sweden. PARTICIPANTS: Seventeen children with cleft lip and palate or cleft palate only and 22 controls aged 7 and 10 years. METHOD: Nasal airflow was transduced with a pneumotachograph attached to a nose mask and registered together with the acoustic speech signal. Sentences containing nasal-to-stop combinations in bilabial, dental, and velar articulatory positions were used. MAIN OUTCOMES MEASURES: The duration from peak to 5% nasal airflow, the maximum flow declination rate, and the nasal airflow at selected points in time during the transition from nasal-to-stop consonants. RESULTS: In the cleft palate group, duration from peak to 5% nasal airflow was clearly longer than among the controls (p <.0001). The declination of airflow was slower (p <.006) and the rate of nasal airflow at the release of the stop consonant was higher (p <.004) in the cleft palate group. Differences between bilabial versus dental and velar articulation were found in the control group. CONCLUSION: Studies of the temporal and dynamic characteristics of the nasal airflow variations during speech appear potentially useful for the assessment of velopharyngeal function.     

The effect of nasopharyngoscopic biofeedback in patients with cleft palate and velopharyngeal dysfunction.

OBJECTIVE: To evaluate the immediate, long-term, and carry-over effects of nasopharyngoscopic biofeedback therapy in patients with cleft palate who exhibit velopharyngeal dysfunction (VPD). DESIGN: Pre- versus posttreatment and follow-up comparisons. SETTING: Cleft palate center of the Heidelberg University Hospital, Heidelberg, Germany. SUBJECTS: Eleven patients with VPD who had received conventional speech therapy without showing significant improvement. INTERVENTIONS: A four-stage feedback procedure. The patients watched and evaluated their velopharyngeal (VP) valving during speech by an endoscopic image displayed on a video monitor. Two feedback sessions took place for every target sound. MAIN OUTCOME MEASURES: Mean occurrence of VP closure during speech sound production on different linguistic levels. Patients' self-perception was assessed by a questionnaire and speech diary. RESULTS: Significant improvement and stability of VP closure was noted. Mean occurrence of VP closure was 5% before therapy, 91% after two biofeedback sessions, and 86% in the follow-up after 6 months. Velopharyngeal dysfunction associated with compensatory articulation proved to be equally well trained as VPD on sounds with good articulatory placement. No significant difference was observed in the degree of improvement between phoneme-specific VPD and generalized VPD. The transfer to the level of words and sentences was successful and showed significant stability. The stability of VP closure for vowels was less than the stability for fricatives and stop sounds. Patients gained improved auditory and kinesthetic self-perception of their articulation. CONCLUSIONS: Nasopharyngoscopic biofeedback therapy proves to be a quick and effective method to change VPD. It shows stable results and carry-over effects.     

Speech outcomes in isolated cleft palate: impact of cleft extent and additional malformations.

OBJECTIVE: The purpose of the study was to study the speech outcome in a series of 5-year-old children born with an isolated cleft palate and compare the speech with that of noncleft children and to study the impact of cleft extent and additional malformation on the speech outcome. DESIGN: A cross-sectional retrospective study. SETTING: A university hospital serving a population of 1.5 million inhabitants. SUBJECTS: Fifty-one patients with an isolated cleft palate; 22 of these had additional malformations. Thirteen noncleft children served as a reference group. INTERVENTIONS: A primary soft palate repair at a mean of 8 months of age and a hard palate closure at a mean age of 4 years and 2 months if the cleft extended into the hard palate. MAIN OUTCOME MEASURES: Perceptual judgment of seven speech variables assessed on a five-point scale by three experienced speech pathologists. RESULTS: The cleft palate group had significantly higher frequency of speech symptoms related to velopharyngeal function than the reference group. There were, however, no significant differences in speech outcome between the subgroup with a nonsyndromic cleft and the reference group. Cleft extent had a significant impact on the variable retracted oral articulation while the presence of additional malformations had a significant impact on several variables related to velopharyngeal function and articulation errors. CONCLUSION: Children with a cleft in the soft palate only, with no additional malformations, had satisfactory speech, while children with a cleft palate accompanied by additional malformations or as a part of a syndrome should be considered to be at risk for speech problems.     

Conversational skills of children with cleft lip and palate: a replication and extension.

OBJECTIVE: To replicate and to extend a previous study examining the conversational skills of children with cleft lip and palate. PARTICIPANTS: Thirty-four children (33 to 44 months) participated: 17 children with cleft lip and palate and 17 noncleft children. METHODS: The children were observed during an interaction with caregivers in their homes. Samples of caregiver-child interactions were coded as assertive or responsive, for type of conversational act, and for discourse level categories. Profiles of conversational activity were determined for each child based on the coding. Correlations were performed to examine the relationship between assertiveness and speech variables (articulation and resonance) for the children with cleft lip and palate. RESULTS: Group comparisons revealed that the children with cleft lip and palate produced fewer assertive utterances, were less likely to respond adequately to comments by caregivers, and produced more topic maintaining and fewer topic extending utterances than did their noncleft peers during conversational interactions. Examination of individual child data indicated that 35% of the children with cleft lip and palate exhibited conversational profiles characterized by either low assertiveness or low responsiveness. Finally, a significant positive correlation was noted between conversational assertiveness and speech production skills. CONCLUSION: These findings suggested that the children with cleft lip and palate were less conversationally assertive than their noncleft peers. Further, there appeared to be a relationship between speech production skills and conversational skills, suggesting that poor speech may be impacting language performance for these children.     

以声学分析法对腭裂术后语音不良机理的初步分析

从声学角度出发应用计算机语音分析技术测试反映腭裂术后患者声道形态特征的元音共振峰。结果表明，腭裂术后语音不良组（Ａ组）除〔ａ〕外，其余５个单元音的第三共振峰频率（Ｆ３）均显著低于腭裂术后语音清晰度组（Ｂ组）（Ｐ＜０．０５）；声学元音图直观显示了（Ａ组）的声学感知空间较（Ｂ组）小。提示腭裂术后语音不良的原因可能系腭裂术后存在不同程度的腭咽闭合不全及腭裂患者长期形成的舌位后移，下颌开度不准和口唇肌运动不协调等代偿性不良发音习惯未得到完全矫正。文中指出，腭裂术后清晰可懂的语音是建立在腭咽闭合完全的基础上，逐渐矫正长期形成的代偿性不良发音习惯的结果。     

频谱分析技术在腭裂语音研究中的应用

目的用语音共振峰的原理建立腭裂语音研究的客观方法。方法对正常儿童、腭裂术前儿童、腭裂术后儿童分别进行单元音[a]、[o]、[e]、[ī]、[u]、[ü]的录音及语音频谱分析,计算各组儿童的第一、二、三共振峰数值,对腭裂术后儿童的腭咽闭合不全率及语音清晰度进行测量,并评价其与共振峰的对应关系。结果正常儿童的第一、二、三共振峰数值是比较恒定的,腭裂术前儿童的共振峰数值明显下降,腭裂术后儿童的共振峰数值随腭咽闭合程度和语音清晰度的改善而显著提高。腭咽闭合完全者发[i]时,F3值明显大于腭咽闭合不全者。结论语音共振峰可以客观地反映腭咽闭合状况,单元音[i]可以作为此种检测的标准音素。     

Phonetic, phonological, and language skills of children with a cleft palate.

OBJECTIVE: To evaluate the language, phonetic, and phonological skills at age 3 years of two groups of young children with a cleft palate, with different expressive language proficiency at 2 years of age. DESIGN: Two groups of children with a cleft palate with differing abilities in early expressive language skills were identified at age 2 years. Comparisons across groups were made over a range of speech and language measures at age 3 years. PARTICIPANTS: Twenty children with cleft palate were allocated to two groups dependent on expressive language abilities at age 2 years. One group had normal language development, and the second group had been identified as having significantly delayed (8 to 12 months' delay) expressive language development. MAIN OUTCOME MEASURES: The children were assessed at 3 years of age using standardized assessments and spontaneous speech samples. Comparisons between the two groups were made on a range of language measures including comprehension, expressive language, and speech. RESULTS: Group differences were found on both language and speech abilities at age 3 years. Significant group differences were found in expressive language, percentage of consonants correct, phonetic inventory, and phonological process usage. The group with delayed early expressive language abilities at 2 years continued to have expressive language difficulties at 3 years of age and had more disordered speech development, compared with the nondelayed group. CONCLUSIONS: A subgroup of children with a cleft palate was identified who exhibited delays in early expressive language and continued to have delayed language and disordered phonological patterns at a later age. Support for three possible etiologies including a structural/anatomical deficit, cognitive/linguistic delay, or language/phonological disorder are discussed.     

腭裂术后构音障碍患者音韵历程的初步分析

目的：分析腭裂术后构音障碍患者音韵历程,为语音治疗提供依据。方法：对46例腭裂术后构音障碍患者的语音资料进行回顾性分析,从腭咽闭合功能、腭瘘、辅音正确构音率（ percentage of consonant correct,PCC）与音韵障碍的相关性方面进行统计研究。结果：46例构音障碍患者中37例出现结构历程,均为声母省略;34例出现位置替代历程,均为后置化;40例出现方法替代历程。患者音韵的结构历程、位置替代历程与PCC分级有相关性。结论：PCC分级高的患者与声母省略的结构历程和后置化的位置替代历程相关。     

强化性语音训练在腭裂术后语音治疗中的应用

目的：采用强化性针对性语音训练以期缩短音训练治疗时间。方法：采用发音部位及发音方式异常针对性语音训练方法,声门停顿音矫治训练方法对患者进行每天１～２次训练,以能发对所有汉语辅音、音节、词组及短句为标准决定训练完成时间。结果：１６名患者经过平均２５ｄ的强化训练后,语音清晰度从平均４９．９％提高到平均８８．２％。平均提高３８．５％。统计学检查有极显著差异性（Ｐ＜０．００１）。结论：强化性针对性语音训练确能在较短时间内达到提高语音清晰度,改善语音功能的目的。     

Effectiveness of intensive articulation therapy for children with cleft palate

The effectiveness of a 6-week summer residential speech program was evaluated for 13 children with cleft lip and palate or cleft palate only. All children received a pretherapy evaluation followed by 4 hours of articulation therapy daily, for 26 days. Speech status was assessed immediately following the intensive therapy program and again on a 9-month follow-up. The findings of this study indicated that while the subjects significantly improved their articulation performance during the program, their progress was much slower than expected. There was no significant difference between the articulation scores obtained immediately posttherapy and those obtained during the 9-month follow-up examination, even though most subjects had received speech therapy during the year through their public school system. Only 3 of the 13 subjects demonstrated better articulation skills during the follow-up examination.     

Laryngeal airway resistance in cleft palate children with complete and incomplete velopharyngeal closure.

OBJECTIVE: This study investigated the effect of velopharyngeal insufficiency on aerodynamic measures of laryngeal function in children with cleft palate. DESIGN: Data were analyzed using analysis of covariance. The independent variable was velopharyngeal closure, and the dependent variables were laryngeal resistance, laryngeal airflow, and transglottal pressure. Age and gender were covariates. SETTING: The data were collected at The Craniofacial Center, University of Illinois, a tertiary health care center located in Chicago. PATIENTS: Thirty-six children with cleft palate were recruited from among the patients at The Craniofacial Center. Ten children with velopharyngeal areas >5 mm2 during oral speech were placed in the incomplete closure group, while 26 children with areas <1 mm2 were placed in the complete closure group. OUTCOME MEASURES: The three dependent variables (transglottal pressure, transglottal airflow, and laryngeal resistance) were measured. RESULTS: Laryngeal resistance and transglottal pressure were significantly higher, and transglottal airflow was significantly lower in the group with complete closure. CONCLUSIONS: In summary, cleft palate patients with complete velopharyngeal closure exhibited higher laryngeal resistances than those with incomplete closure.     

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.     

The effects of Le Fort I osteotomy with maxillary movement on articulation, resonance, and velopharyngeal function

Articulation, resonance, and velopharyngeal function were evaluated before and after Le Fort I maxillary advancement in 16 patients (seven with cleft lip and palate, one with cleft lip only, and eight without clefts). On the postoperative evaluation, seven of 11 patients with preoperative articulation errors showed an improvement in articulation after surgery. Two patients without clefts showed slight changes in nasal resonance, and two patients (one with cleft lip and palate and one with cleft lip only) developed mild nasal emission. Nine patients showed diminished velopharyngeal contact during speech on videofluoroscopic studies. Compensatory changes in velopharyngeal function were also observed, which included velar stretching and lengthening and increased lateral pharyngeal wall movement.     

两种腭裂修复方式治疗过宽不完全腭裂的临床效果比较

目的:比较兰氏法和改良兰氏法修复过宽不完全腭裂的临床效果。方法:选取2012年1月~2014年12月于徐州医科大学附属徐州市立医院接受腭裂修复术的不完全腭裂患儿40例,年龄2~5岁,裂隙宽度均大于2.5 cm,按接受腭裂修复的不同方式分为2组,实验组:20例,行改良兰氏法(兰氏法联合颊肌黏膜瓣)修复腭裂,对照组:20例,行兰氏法修复腭裂。2017年1月~2019年9月(术后5~7年)进行随访,此时两组患者年龄7~9岁,平均年龄为8岁。分别观察两组患者术区恢复状态,应用锥形束CT(CBCT)观察比较上颌骨发育情况,使用头颅侧位片评价腭咽闭合功能,并且进行语音清晰度评估。结果:相比于对照组,实验组的患者恢复较好,术区瘢痕轻微,上颌骨发育好,腭咽闭合完全,语音清晰度高。结论:对于裂隙过宽的腭裂患者,使用联合颊黏膜瓣的兰氏法可有效避免裸露的骨面,减轻了瘢痕增生,有利于上颌骨发育,增进腭咽闭合,提高了语音清晰度是一种更为值得推广的腭裂新手术方法。     

Clinical outcomes of the furlow z-plasty for primary cleft palate repair

Objective: To review the clinical outcomes following the Furlow Z-plasty for primary cleft palate repair. The primary objective was to determine if the presence of an associated sequence or syndrome (i.e., Pierre Robin sequence), age at palate repair, cleft type, or surgeon experience influenced speech outcomes after a Furlow Z-plasty. Design: The outcomes of 140 patients who underwent palate repair were analyzed retrospectively. Speech evaluations were performed to score the severity of hypernasality, nasal escape, articulation errors, and velopharyngeal insufficiency. Results: The mean age at latest evaluation was 4 years 9 months (age range 2 years old to 12 years old and 4 months). Of the 140 patients, 83% had no evidence of hypernasality, 91% had no presence of nasal escape, and 69% had no articulation errors. Overall, 84% of patients had no evidence of velopharyngeal insufficiency. Secondary posterior pharyngeal flap to correct velopharyngeal insufficiency was required in only 2.1% of patients. The formation of an oronasal fistula occurred in only 3.6% of patients. Nonsyndromic patients with Pierre Robin sequence and syndromic patients did just as well as purely nonsyndromic patients in terms of velopharyngeal insufficiency, hypernasality, and nasal escape. Syndromic patients were more likely to make mild-to-moderate articulation errors. In addition, age at palate repair, cleft type, and surgeon experience had no statistically significant effect on speech results. Conclusions: The Furlow Z-plasty yielded excellent speech results in our patient population with minimal and acceptable rates of fistula formation, velopharyngeal insufficiency, and the need for additional corrective surgery.     

Perceptual evaluation of speech and velopharyngeal function in children with and without cleft palate and the relationship to nasal airflow patterns.

OBJECTIVES: The aim was to study the relationship between perceptual evaluation of speech variables related to velopharyngeal function and the pattern of nasal airflow during the velopharyngeal closing phase in speech in children with and without cleft palate. PARTICIPANTS: Fourteen children with cleft lip and palate or cleft palate only and 15 controls aged 7 and 10 years. All were native Swedish speakers. METHOD: Three experienced listeners performed a blinded perceptual speech evaluation. Nasal airflow was transduced with a pneumotachograph attached to a nasal mask. The duration from peak to 5% nasal airflow, maximum flow declination rate, and nasal airflow at selected points in time during the transition from nasal to stop consonants in bilabial and velar articulatory positions in sentences were estimated. The analysis was focused on the perceptual ratings of "velopharyngeal function" and "hypernasality." RESULTS: A strong association was found between ratings of "velopharyngeal function" and "hypernasality" and the pattern of nasal airflow during the bilabial nasal-to-stop combination /mp/. Both the sensitivity and specificity were 1.00 for the bilabial temporal airflow measure in relation to ratings of "velopharyngeal function." The nasal airflow rate during /p/ in /mp/ had a sensitivity of 1.00 and specificity of 0.92 to 0.96 in relation to ratings of "hypernasality." CONCLUSION: Assessment of the nasal airflow dynamics during the velopharyngeal closing phase in speech presents quantitative, objective data that appear to distinguish between perceptually normal and deviant velopharyngeal function with high sensitivity and specificity.     

Speech outcome in children with cleft palate: aerophonoscope assessment of nasal emission.

The quality of speech is an important outcome measure of the success of primary surgery for clefts of the palate. A competent velopharyngeal mechanism is essential for normal speech, and disorders of resonance and nasal airflow are significant manifestations of velopharyngeal dysfunction in cleft palate subjects. The aim of this study was to determine the level of nasal emission during speech in patients with functionally repaired clefts of the palate and compare this with age and sex-matched controls. Forty-four children between the ages of 3 and 9 years were assessed for nasal emission using an Aerophonoscope. All these patients had primary functional surgery carried out at this unit by the same surgeon, and fell into three groups; complete bilateral, complete unilateral and soft palate clefts. Nasal breathing, blowing and groups of vowels and voiceless pressure consonants were assessed. There was no nasal emission in close to, or over, 90% of the patients for these parameters. The results indicate that a highly significant percentage of children with functionally repaired clefts of the palate have normal velopharyngeal function and speech, without inappropriate nasal emission. The Aerophonoscope provides an accurate, reliable and user-friendly diagnostic aid, and indeed therapeutic adjunct, to speech management in cleft palate patients.