Melina Evangelista Whitaker

Prospective clinical trial comparing outcome measures between Furlow and von Langenbeck Palatoplasties for UCLP.

The goal of this prospective randomized clinical trial was to compare 2 cohorts of standardized cleft patients with regard to functional speech outcome and the presence or absence of palatal fistulae. The 2 cohorts are randomized to undergo either a conventional von Langenbeck repair with intravelar velarplasty or the double-opposing Z-plasty Furlow procedure. A prospective 2 × 2 × 2 factorial clinical trial was used in which each subject was randomly assigned to 1 of 8 different groups: 1 of 2 different lip repairs (Spina vs. Millard), 1 of 2 different palatal repair (von Langenbeck vs. Furlow), and 1 of 2 different ages at time of palatal surgery (9–12 months vs. 15–18 months). All surgeries were performed by the same 4 surgeons. A cul-de-sac test of hypernasality and a mirror test of nasal air emission were selected as primary outcome measures for velopharyngeal function. Both a surgeon and speech pathologist examined patients for the presence of palatal fistulae. In this study, the Furlow double-opposing Z-palatoplasty resulted in significantly better velopharyngeal function for speech than the von Langenbeck procedure as determined by the perceptual cul-de-sac test of hypernasality. Fistula occurrence was significantly higher for the Furlow procedure than for the von Langenbeck. Fistulas were more likely to occur in patients with wider clefts and when relaxing incisions were not used.

Proposta de protocolo de avaliação clínica da função mastigatória

PURPOSE: to elaborate a protocol for the clinical evaluation of the masticatory function, aiming at aiding the speech pathologist to identify and interpret the clinical signals of the masticatory disorders, in its dynamics, in addition to allowing for inter-judge comparison and treatment continuation. METHODS: this protocol was elaborated based on the clinical practice of the speech pathologists that answered to a questionnaire sent by email; in the literature, according to the identification of the common points to all chewing evaluation protocols; in addition to the experience of the speech pathologists of HRAC/USP. RESULTS: the protocol for the clinical chewing evaluation considers aspects related to morphologic aspects and neurophysiology of the masticatory function. Conclusion: this study contributes to Speech Pathology, once that it searches, in the most possible complete manner, criteria for evaluating the chewing, guiding the clinical speech-language performance based on evidences.

Speech therapy for compensatory articulations and velopharyngeal function: a case report

The objective of this study was to describe the process of intensive speech therapy for a 6-year-old child using compensatory articulations while presenting with velopharyngeal insufficiency (VPI) and a history of cleft lip and palate. The correction of VPI was temporarily done with a pharyngeal obturator since the child presented with very little movement of the pharyngeal walls during speech, compromising the outcome of a possible pharyngeal flap procedure (pharyngoplasty). The program of intensive speech therapy involved 3 phases, each for duration of 2 weeks incorporating 2 daily sessions of 50 minutes of therapy. A total of 60 sessions of intervention were done with the initial goal of eliminating the use of compensatory articulations. Evaluation before the program indicated the use of co-productions (coarticulations) of voiceless plosive and fricative sounds with glottal stops (simultaneous production of 2 places of productions), along with weak intraoral pressure and hypernasality, all compromising speech intelligibility. To address place of articulation, strategies to increase intraoral air pressure were used along with visual, auditory and tactile feedback, emphasizing the therapy target and the air pressure and airflow during plosive and fricative sound productions. After the first two phases of the program, oral place of articulation of the targets were achieved consistently. During the third phase, velopharyngeal closure during speech was systematically addressed using a bulb reduction program with the objective of achieving velopharyngeal closure during speech consistently. After the intensive speech therapy program involving the use of a pharyngeal obturator, we observed absence of hypernasality and compensatory articulation with improved speech intelligibility.

Relationship between occlusion and lisping in children with cleft lip and palate.

Introduction The literature suggests that individuals with history of cleft lip and palate who present with midfacial growth deficiency are at higher risk of presenting lisping. The relationship between distortions during production of linguoalveolar fricative sounds and the severity of malocclusion, however, has not been established for the population with cleft. Objective To study the association between lisping and dental arch relationship. Methodology Speech samples and dental arch casts were obtained from 106 children with operated unilateral cleft lip and palate (UCLP) during the stage of mixed dentition and before orthodontic treatment. Videotaped productions of the phrase lu saci saiw sedul were rated by speech-language pathologists for the identification of lisping during [s]. Dental arch casts were rated by orthodontists using the Goslon Yardstick and the Five-Year Index to establish dental arch relationship. Results Multiple logistic regression showed no significant association between lisping and dento-occlusal index (p = .802) and age (p = .662). Substantial interjudge agreement during auditory-perceptual ratings was found (kappa = .63). Almost perfect agreement was found between orthodontists while establishing the dental arch relationship (kappa = .81). Discussion This study failed to reveal an association between lisping and dental arch relationship in children with operated UCLP. Multiple variables may play a role in determining occurrence of lisping, warranting further investigation.

Speech nasality and nasometry in cleft lip and palate

INTRODUCTION Perceptual evaluation is considered the gold standard to evaluate speech nasality. Several procedures are used to collect and analyze perceptual data, which makes it susceptible to errors. Therefore, there has been an increasing desire to find methods that can improve the assessment. OBJECTIVE To describe and compare the results of speech nasality obtained by assessments of live speech, the Test of Hypernasality (THYPER), assessments of audio recorded speech, and nasometry. METHODS A retrospective study consisting of 331 patients with operated unilateral cleft lip and palate. Speech nasality was assessed by four methods of assessment: live perceptual judgement, THYPER, audio-recorded speech sample judgement by multiple judges, and nasometry. All data were collected from medical records of patients, with the exception of the speech sample recording assessment, which was carried out by multiple judges. RESULTS The results showed that the highest percentages of absence of hypernasality were obtained from judgements performed live and from the THYPER, with equal results between them (79%). Lower percentages were obtained from the recordings by judges (66%) and from nasometry (57%). CONCLUSION The best results among the four speech nasality evaluation methods were obtained for the ones performed live (live nasality judgement by a speech pathologist and THYPER).

Nasoendoscopic findings after primary palatal surgery: can the Furlow technique result in a smaller velopharyngeal gap?

PURPOSE To compare the nasoendoscopic findings related to the velopharyngeal gap among patients with cleft palate who underwent the Furlow (F) technique and those who underwent the von Langenbeck (vL) technique for primary palatal surgery, who remained with velopharyngeal insufficiency (VPI). METHODS The analyzed data were retrieved from the institutions data of recordings of nasoendoscopic exams. The sample comprised 70 recorded nasoendoscopic exams obtained from 22 patients who underwent the F technique and from 48 who underwent the vL technique during primary palatoplasty, who remained with VPI after surgery and were submitted to nasoendoscopy, between the ages of 5 and 15 years (mean age: 8 years), for definition of the best treatment for VPI. The images were edited into a DVD in a randomized sequence to be assessed by three experienced speech language pathologists regarding displacement and excursion of the soft palate; displacement and excursion of lateral pharyngeals walls; displacement and excursion of the posterior pharyngeals wall; and presence of the Passavant ridge and size and type of velopharyngeal gap. RESULTS The results of the comparison of measurements between F and vL groups were not statistically significant. CONCLUSION The surgical technique used in primary palatoplasty was not relevant to determine the difference in the size of the velopharyngeal gap for patients who maintained VPI.

Ocorrência de ceceio em fricativas vozeadas e não vozeadas em crianças com fissura labiopalatina operada

Purpose to investigate whether lisp, when identified, differs between voiced and unvoiced alveolar fricatives produced by children with cleft palate. Methods a prospective study in which sentences comprising the consonants [s] and [z] produced by 32 children with cleft palate (mean age, 8 years, 8 months) were selected and after auditory judged. All children presented altered inter-relationship arches as evaluated by three orthodontists (inter-judge agreement almost perfect kappa = 0.81), performing analysis of dental casts. Three Speech-Language-Pathologists judged perceptually audio recorded productions. The inter-judges agreement ranged between 56% and 78% and between 59% and 93% for the phrases consisting of [s] and [z], respectively. Results the lisp was identified in 69% of children, particularly, in 72% and 50% [s] and [z] sounds, respectively. There were significant differences between judgments for the fricatives [s] and [z], with higher prevalence of lisping in [s]. Conclusions dentofacial deformities may favor the occurrence of lisp in population with cleft palate. The increased occurrence of lisp in [s] compared to [z], based on auditory perceptual identification, can be justified by acoustic and / or articulatory reasons. It is suggested that lisp is dependent of the phonetic-phonological context of the sentence and therefore must be considered for clinical and research purposes.

Concordância entre os testes perceptivos e a videofluoroscopia no diagnóstico da disfunção velofaríngea

Purpose: To determine the agreement between the results of the Nasal Air Emission and Hypernasality tests and the videofluoroscopy findings in the diagnosis of velopharyngeal dysfunction in individuals with cleft lip and palate. Methods: The sample consisted of 89 scores of Nasal Air Emission and Hypernasality tests and 89 judgments of videofluoroscopy recordings, which were interpreted as consistent velopharyngeal closure, or as inconsistent velopharyngeal closure, or as non velopharyngeal closure. The sensitivity, specificity and agreement between the interpretation of the re sults of the perceptual tests and the findings of the videofluoroscopy were calculated. Results: The rates found for sensitivity of Nasal Air Emission and Hypernasality tests were 98% and 96%, respectively, and the rates for specificity of Nasal Air Emission and Hypernasality tests were 37% and 63%, respectively. Regarding the percentages of agreement between the Nasal Air Emission test scores and the videofluoroscopy judgments, it was found an agreement of 62% for the consistent velopharyngeal closure condition, 43% for the inconsistent velopharyngeal closure, and 68% for the non velopharyngeal closure. Between the scores of Hypernasality test and videofluoroscopy judgments the agreement found was 70% for the consistent velopharyngeal closure condition, 47% for the inconsistent velopharyngeal closure and 77% for the non velopharyngeal closure. Conclusion: There was a good level of agreement between the perceptual tests and the videofluoroscopy judgments for the consistent velopharyngeal closure and non velopharyngeal closure conditions, but not for the inconsistent velopharyngeal closure.