Gunilla Henningsson

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.

Methodology for Speech Assessment in the Scandcleft Project—An International Randomized Clinical Trial on Palatal Surgery: Experiences from a Pilot Study:

Objective: To present the methodology for speech assessment in the Scandcleft project and discuss issues from a pilot study. Design: Description of methodology and blinded test for speech assessment. Speech samples and instructions for data collection and analysis for comparisons of speech outcomes across five included languages were developed and tested. Participants and Materials: Randomly selected video recordings of 10 5-year-old children from each language (n  =  50) were included in the project. Speech material consisted of test consonants in single words, connected speech, and syllable chains with nasal consonants. Five experienced speech and language pathologists participated as observers. Main Outcome Measures: Narrow phonetic transcription of test consonants translated into cleft speech characteristics, ordinal scale rating of resonance, and perceived velopharyngeal closure (VPC). A velopharyngeal composite score (VPC-sum) was extrapolated from raw data. Intra-agreement comparisons were performed. Results: Range for intra-agreement for consonant analysis was 53% to 89%, for hypernasality on high vowels in single words the range was 20% to 80%, and the agreement between the VPC-sum and the overall rating of VPC was 78%. Conclusions: Pooling data of speakers of different languages in the same trial and comparing speech outcome across trials seems possible if the assessment of speech concerns consonants and is confined to speech units that are phonetically similar across languages. Agreed conventions and rules are important. A composite variable for perceptual assessment of velopharyngeal function during speech seems usable; whereas, the method for hypernasality evaluation requires further testing.

A four-year longitudinal study of palatal plate therapy in children with Down syndrome: effects on oral motor function, articulation and communication preferences.

The orofacial function in 20 children with Down syndrome was evaluated after 4 years of palatal plate therapy in 9 of the children (PPG); the remaining 11 were untreated age-matched controls (CG). All 20 children had received continuous orofacial physical therapy from their speech therapist during the treatment period. A clinical extra- and intraoral examination was performed, including oral motor function, facial expression, the occurrence of malocclusions, and hypertrophic tonsils. A questionnaire requesting data on breathing patterns, drooling, eating problems, and communicative preferences was answered by the parents. An articulation assessment was performed by two speech and language pathologists blinded to the treatment status of the children in order to find out whether the palatal plate had stimulated to improved oral speech behavior. The results for oral motor function showed significant differences between the groups in favor of the PPG for the summary variables for: visible tongue (P < 0.01), visible tongue during non-speech periods (P < 0.05), and lip-rounding during spontaneous speech (P < 0.01). During non-speech time, the PPG had their mouths open significantly less than the CG (P < 0.05). Expressivity of facial expression on a visual analog scale in the PPG scored 75.6 ± 13.3 compared to 51.8 ± 25.7 in the CG (P < 0.05). The intraoral examination showed that 6/9 children in the PPG and 7/11 in the CG had enlarged tonsils, resulting in more than 50% inter-tonsillary space reduction. Despite these findings, and no significant differences between the groups with respect to mouth/nose breathing, nocturnal snoring was significantly less in the PPG than in the CG (P < 0.05), according to the parental questionnaire. After 4 years of palatal plate therapy, orofacial function had improved significantly in the 9 PPG children and specifically in terms of tongue position and lip activity.

A SIX-CENTRE INTERNATIONAL STUDY OF THE OUTCOME OF TREATMENT IN PATIENTS WITH CLEFTS OF THE LIP AND PALATE: THE RESULTS OF A CROSS-LINGUISTIC INVESTIGATION OF CLEFT PALATE SPEECH

Speech samples of 131 subjects with complete unilateral clefts of the lip and palate from six European cleft palate centres were analysed and assessed using a specifically designed phonetic framework. This framework focused on consonants that are ?vulnerable? in speech associated with cleft palate and common to the five languages of the project. The methodology used and the results of the reliability study are reported. Consonant articulation, resonance, and voice quality are also evaluated. The results show good outcomes with regard to consonant articulation across the whole study group with common areas of minor difficulty across languages. The results for resonance were less good, with slight hypernasality in 20% of subjects. There were, however, few indications of seriously disordered speech. The detectable differences between centres match the findings of the Eurocleft Orthodontic Group particularly in regard to the ranking of the centres.

Influence of palatal fistulas on velopharyngeal movements: a cineradiographic study.

Ten patients with hard palate fistulas and velopharyngeal incompetence were examined cineradiographically with lateral and frontal projections during connected speech. The purpose was to study velopharyngeal function for open versus covered fistulas. Fistula length, width, and size were measured. With an open fistula, the degree of lateral pharyngeal wall activity was significantly correlated at the 0.05 level to fistula size. There was no statistically significant correlation between fistula size and the degree of velar activity. With the fistula covered, the velopharyngeal movements improved or even normalized in all patients regardless of fistula size. These findings indicate that patients with both velopharyngeal incompetence and an additional fistula will need covering of the fistula. If velopharyngeal incompetence persists after a temporary covering of the fistula, a combination of velopharyngeal flap surgery and fistula covering ought to be performed to normalize the velopharyngeal activity and speech and resonance.

Speech Outcome Following Treatment in Cross-Linguistic Cleft Palate Studies: Methodological Implications

Objective In cross-linguistic studies of cleft palate speech outcome following treatment, treatment is the independent variable, speech outcome is the dependent variable, and the speakers’ language background is a background variable, like sex, age, and cleft type, which must be eliminated. This article focuses on language as a background variable and how it should be treated. The methodological problems are illustrated through a presentation of two cross-linguistic speech outcome studies. Conclusion When speakers of different language background are included in cleft palate studies of speech outcome following treatment, speech outcome data should be based on speech units that are phonetically identical across languages. This affects the make-up of the speech material used in the study. In practice, the requirement of phonetically identical speech units may not be totally met, and detailed information regarding the interaction between the cleft condition and speech sound production is still required to fully understand how the validity of data is affected if this requirement is not met.

Speech in Unilateral and Bilateral Cleft Palate Patients from Stockholm

The speech of 84 patients with complete unilateral cleft lip and palate and 19 patients with complete bilateral cleft lip and palate was judged by professional listeners and compared with a control group of 40 noncleft subjects. The unilateral cleft group consisted of two subgroups: one group of 45 patients, who were treated with presurgical orthopedics before primary surgery, and one group of 39 patients, who were not. The speech of the patients and the noncleft subjects was tape recorded and randomly mixed prior to listener judgments. No significant differences in articulation or resonance were found between the subgroups of unilateral cleft patients. The results also indicated that the bilateral cleft patients had poorer speech and needed more speech therapy than the unilateral cleft patients. All cleft patients were found to have poorer speech than the noncleft subjects in spite of considerable speech therapy and complementary surgical treatment. This has resulted in a change in the Stockholm approach toward earlier palatal surgery, tailor-made pharyngeal flap operations, and earlier parental information and treatment of articulatory deviations.

A phonetic framework for the cross-linguistic analysis of cleft palate speech

The Eurocleft Speech Group was formed in 1989. The group is made up of eight speech and language therapists/logopedists from the six centres involved in the Eurocleft Orthodontic study, (Amsterdam/Rotterdam, Copenhagen, London, Manchester, Oslo, Stockholm) a clinical phonetician/speech and language therapist, (advisor on statistical analytical techniques) and a professor of clinical linguistics (director of the group). This six-centre international study of cleft palate speech presented major methodological problems, which appeared to be unprecedented in this area of speech pathology research. A research protocol had to be devised that would provide comparable information about the speech of children from five different language backgrounds. This paper describes the analytical framework developed for this purpose. This framework takes account of the common phonetic characteristics of the five target languages and the possible effects of the cleft palate condition on the realization of these phonetic targe...

Comparison Between Two Types of Pharyngeal Flap with Regard to Configuration at Rest and Function and Speech Outcome

OBJECTIVE In management of hypernasality, wide pharyngeal flaps have been advocated when pharyngeal wall adduction is limited. Pharyngeal flaps merged into a transversely split velum (TS flaps) are reported to be wider than if the velum is split in the midline (MS flaps). The hypothesis to be tested was that TS flaps are wider than MS flaps and are more caudally based. DESIGN In this prospective study, MS flaps were videoradiographically and nasopharyngoscopically compared with TS flaps at both rest and function. Pharyngoplasty was randomly performed by one of three surgeons and the radiographic examinations were carried out by one radiologist. The speech was assessed pre- and postoperatively. SETTING The Stockholm Cleft Palate Team, Sweden, treated all patients. PATIENTS After strict selection of the patients to avoid any uncontrolled impact on velopharyngeal sphincter function, 22 patients with limited pharyngeal adduction received TS flaps and 20 patients with good adduction received MS flaps. RESULTS The data failed to show any difference in location of flap base and in flap width at rest. During function, TS flaps demonstrated statistically significant widening of the flap base. TS flaps, but not MS flaps, often had a bulge that appeared to assist velopharyngeal closure in some patients. Speech evaluation revealed that both flap types corrected velopharyngeal insufficiency equally well. CONCLUSIONS TS flaps were not wider than MS flaps, and functional plasticity of the TS flap appeared essential for elimination of velopharyngeal insufficiency. Contribution of postoperative adaptation of the pharyngeal wall adduction remains to be clarified.

Oronasal fistulas in cleft palate patients and their influence on speech

The size, site, and influence on speech of oronasal fistulas were studied in 12 patients with unilateral and 32 with bilateral cleft lip and palate. There were more and larger fistulas in the bilateral group. The series was divided into: those with fistulas that affected speech (group A, n = 18) and those with fistulas that did not affect their speech (group B, n = 26). Group A had significantly larger fistulas than group B, but there were no differences in the sites of the fistulas, either between the bilateral and unilateral groups or between groups A and B. Most fistulas were located in the region of the incisive foramen or in the hard palate. Judgements by listeners and analyses by the NORAM instrument were made of the speech of 12 of the patients in group A before and after temporary covering of the fistulas. Significant differences in hypernasality, according to both listeners judgments and instrumental analyses were found. This finding is further evidence that an oronasal fistula can influence and contribute to velopharyngeal dysfunction.