Debbie Sell

Universal parameters for reporting speech outcomes in individuals with cleft palate

Objective: To achieve consistency and uniformity in reporting speech outcomes in individuals born with cleft palate with or without cleft lip using perceptual parameters that characterize their speech production behavior regardless of the language or languages spoken. Design: A working group of six individuals experienced in speech and cleft palate was formed to develop a system of universal parameters for reporting speech outcomes in individuals born with cleft palate. The system was adopted in conjunction with a workshop held in Washington, D.C., that was devoted to developing the universal system. The system, which was refined further following the workshop, involves a three-stage plan consisting of (1) evaluation, (2) mapping, and (3) reporting. The current report focuses primarily on the third stage, reporting speech outcomes. Results: A set of five universal speech parameters has been devised for the reporting stage. These consist of (1) hypernasality, (2) hyponasality, (3) audible nasal air emission and/or nasal turbulence, (4) consonant production errors, and (5) voice disorder. Also included are speech understandability and speech acceptability, global parameters that can be reported for any type of speech disorder. The parameters are described in detail, and guidelines for speech-sampling content and scoring procedures in relation to the parameters are presented. Conclusion: A plan has been developed to document speech outcomes in individuals with cleft palate, regardless of the spoken language, using a set of five universal reporting parameters and two global speech parameters.

GOS.SP.ASS.'98: an assessment for speech disorders associated with cleft palate and/or velopharyngeal dysfunction (revised)

In 1994 the present authors proposed a speech assessment protocol for speech disorders associated with cleft palate and/or velopharyngeal dysfunction known as GOS.SP.ASS. (Great Ormond Street Speech Assessment). In a recent survey undertaken to review the different speech assessment protocols used in six cleft palate centres in the UK, GOS.SP.ASS. was selected from six protocols as the optimal procedure for clinical and research purposes. The process of identifying an optimal procedure involved analysis of completed forms for each assessment. Analysis of the completed GOS.SP.ASS. forms revealed significant ambiguities in the protocol which led to differences in form completion. This paper describes important revisions to the original GOS.SP.ASS. protocol in order to ensure comparable data from different clinicians. This detailed speech assessment is now complemented by the Cleft Audit Protocol for Speech (CAPS), a tool recommended for clinical audit. As a result of close collaboration in their preparation, the results are directly comparable. In addition, the speech elicitation sentences and the phonetic diagram have been modified.

Palate re-repair revisited.

OBJECTIVE To analyze the results of a consecutive series of palate re-repairs performed using the operating microscope and identify predictive factors for outcome. DESIGN Prospective data collection, with blind assessment of randomized recordings of speech and velar function on lateral videofluoroscopy and nasendoscopy. PATIENTS One hundred twenty-nine consecutive patients with previously repaired cleft palates and symptomatic velopharyngeal incompetence (VPI) and evidence of anterior insertion of the levator veli palatini underwent palate re-repairs by a single surgeon from 1992 to 1998. Syndromic patients, those who had significant additional surgical procedures at the time of re-repair (23 patients), and all patients with inadequate pre- or postoperative speech recordings were excluded, leaving a total of 85 patients in the study. INTERVENTIONS Palate re-repairs, with radical dissection and retropositioning of the velar muscles, were performed using the operating microscope with intraoperative grading of anatomical and surgical findings. MAIN OUTCOME MEASURES Pre- and postoperative perceptual speech assessments using the Cleft Audit Protocol for Speech (CAPS) score, measurement of velar function on lateral videofluoroscopy, and assessment of nasendoscopy recordings. RESULTS There were significant improvements in hypernasality, nasal emission, and nasal turbulence and measures of velar function on lateral videofluoroscopy, with improvement in the closure ratio, velopharyngeal gap at closure, velar excursion, velar movement angle, and velar velocity. CONCLUSIONS Palate re-repair has been shown to be effective in treating VPI following cleft palate repair, both in patients who have not had an intravelar veloplasty and those who have had a previous attempt at muscle dissection and retropositioning. Palate re-repair has a lower morbidity and is more physiological than a pharyngoplasty or pharyngeal flap.

Issues in perceptual speech analysis in cleft palate and related disorders: a review

BACKGROUND Perceptual speech assessment is central to the evaluation of speech outcomes associated with cleft palate and velopharyngeal dysfunction. However, the complexity of this process is perhaps sometimes underestimated. AIMS To draw together the many different strands in the complex process of perceptual speech assessment and analysis, and make recommendations for practice. MAIN CONTRIBUTION This review examines issues such as data sampling, data collection/recording, archiving, the advantages and disadvantages of lay and specialist listeners, approaches to data analysis, reliability, and data interpretation. CONCLUSIONS The need to capture meaningfully the sound of speech based on detailed phonetic analysis is argued. Also described are some of the differences in measuring speech for clinical, audit and research activities. Blind independent analysis of speech data by specialist therapists is recommended as the gold standard methodological approach when reporting audit and research outcomes. The requirement for ongoing training in listening skills for specialist therapists is advocated. The limitations of an impairment-based-only approach to measurement are also illustrated, indicating the need to develop outcome measures that incorporate more functional issues that affect quality of life.

Cleft lip and palate care in the United Kingdom - The Clinical Standards Advisory Group (CSAG) study. Part 2: Dentofacial outcomes and patient satisfaction

OBJECTIVE To describe facial development and appearance, quality of bone grafts, oral health, and patient/parent satisfaction, with clinical outcome, for children in two age cohorts born with unilateral cleft lip and palate (UCLP) throughout the United Kingdom. DESIGN Cross-sectional outcome study. SETTING Fifty National Health Service cleft centers. PARTICIPANTS Children born with complete UCLP between April 1, 1982, and March 31, 1984, (12-year-olds) and April 1, 1989, and March 31, 1991 (5-year-olds). Data were collected for 239 5-year-olds and 218 12-year-olds. The parents of these children were also interviewed to determine levels of satisfaction with care received. MAIN OUTCOME MEASURES Skeletal pattern, dental arch relationship, success of alveolar bone grafting, facial appearance, oral health status, and patient/parent satisfaction. RESULTS Nearly 40% of 5- and 12-year-olds had poor dental arch relations, and 70% of 12-year-olds had midface retrusion. Fifteen percent of 12-year-olds had not received an alveolar bone graft, and only 58% of bone grafts that had been undertaken were successful. Twenty percent of 12-year-olds and 40% of 5-year-olds had untreated dental caries. Less than one-third of subjects had a good facial appearance as judged by a panel of experts. Levels of patient and parent satisfaction were generally high. CONCLUSION A rigorous evaluation of cleft care in the United Kingdom reveals disappointing outcomes.

Cleft lip and palate care in the United Kingdom: The clinical standards advisory group (CSAG) study. Part 4 : Outcome comparisons, training, and conclusions

OBJECTIVE A critical appraisal of cleft care in the United Kingdom. DESIGN Retrospective comparative study. SETTING All National Health Service cleft centers in the United Kingdom. PATIENTS/PARTICIPANTS Children born with unilateral complete clefts of the lip and palate between April 1, 1982, and March 31, 1984 (12-year-olds), and April 1, 1989, and March 31, 1991 (5-year-olds). Newly appointed and senior cleft clinicians. MAIN OUTCOME MEASURES Skeletal pattern, dental arch relationship, success of alveolar bone grafting, dental health, facial appearance, oral health status, patient/parent satisfaction. CONCLUSIONS This paper highlights the poor outcomes for the fragmented cleft care in the United Kingdom, compared with European centers. There is an urgent need for a review of structure, organization, and training.

Relationship between perceptual ratings of nasality and nasometry in children/adolescents with cleft palate and/or velopharyngeal dysfunction

BACKGROUND Nasometry has supplemented perceptual assessments of nasality, using speech stimuli, which are devoid of nasal consonants. However, such speech stimuli are not representative of conversational speech. A weak relationship has been found in previous studies between perceptual ratings of hypernasality and nasalance scores for passages containing nasal consonants. AIMS This study aimed to evaluate the relationship between perceptual assessment and acoustic measurements of nasality using controlled speech stimuli. METHODS & PROCEDURE A perceptual scale (the Temple Street Scale) describing nasality was devised for this study. Fifty children presenting with nasality were assessed using the Temple Street Scale and nasalance scores were obtained for specified speech samples using the Nasometer (Kay Elemetrics 6200.3). The relationship between the perceptual ratings and the nasometry results was evaluated using correlation analysis, test sensitivity, specificity, and overall efficiency. OUTCOMES & RESULTS Correlation coefficients for perceptual ratings of nasality and nasalance scores ranged from 0.69 to 0.74. The sensitivity of the Nasometer ranged from 0.83 to 0.88; its specificity ranged from 0.78 to 0.95; while its overall efficiency was between 0.82 and 0.92. CONCLUSIONS The strong relationship between perceptual and acoustic assessments of nasality indicated that the Temple Street Scale and the Nasometer are both valid clinical tools for the evaluation of nasality when a carefully constructed speech sample is used. The need to use the Nasometer as a supplement to perceptual assessment is highlighted.

A screening assessment of cleft palate speech (Great Ormond Street Speech Assessment)

This paper presents a comprehensive screening procedure for describing the speech characteristics commonly associated with cleft palate and/or velopharyngeal dysfunction. A unique method of representing the information visually is proposed. The theoretical background and recommendations for clinical application are discussed. This procedure is designed for use by specialist and non-specialist speech and language therapists working in this field. It has been developed primarily with a child population but can be used with all age groups. It provides a structure for assessment, record keeping, report writing and research, thereby facilitating the development of intercentre studies.

The Nature of Feeding in Infants With Unrepaired Cleft Lip and/or Palate Compared With Healthy Noncleft Infants

Objective: Feeding difficulties are reported widely in infants with cleft lip and/ or palate. There is, however, a paucity of objective information about the feeding patterns of these infants. This study compared patterns of feeding in infants with unrepaired cleft lip and palate with healthy noncleft infants of a similar age. Setting: North Thames Regional Cleft Centre. The noncleft cohort was recruited from West Middlesex University Hospital, a general hospital with similar demographics. Participants: Fifty newborn infants with nonsyndromic complete unilateral cleft lip and palate or a cleft of the soft and at least two thirds of the hard palate who were referred to the North Thames Regional Cleft Centre participated. Parents of 20 randomly selected, noncleft infants agreed to participate. Main Outcome Measures: Feeding patterns were rated using the Neonatal Oral Motor Assessment Scale. Additional objective information was collected using the Great Ormond Street Measurement of Infant Feeding (Masarei et al., 2001; Masarei, 2003). Results: Infants with nonsyndromic complete unilateral cleft lip and palate or a cleft of the soft and at least two thirds of the hard palate had less efficient sucking patterns than their noncleft peers had. They used shorter sucks (mean difference, 0.30 second; p < .0005), a faster rate of sucking (mean difference, 34.20 sucks/second; p < .0005), higher suck-swallow ratios (mean difference, 1.87 sucks/swallow; p < .0005), and a greater proportion of intraoral positive pressure generation (mean difference, 45.97% positive pressure; p < .0005). Conclusions: This study demonstrated that the sucking patterns of infants with nonsyndromic complete unilateral cleft lip and palate or a cleft of the soft and at least two thirds of the hard palate differ from those of their noncleft peers.

Cleft palate speech dissected: a review of current knowledge and analysis

In this review, normal speech and its development is described and compared with the patterns typical of cleft palate speech. Attention is drawn to the importance of measuring and analysing these factors adequately for research and audit purposes, and the need for agreed parameters for reporting outcomes.