Protocols for Reporting Speech Outcomes following Palatoplasty or Velopharyngeal Surgery: A Literature Review

Exploration of the Utility of the Generic ICHOM Standard Set Measures in Evaluating the Speech of Patients with Cleft Lip/Palate

Background

The International Consortium of Health Outcome Measurements (ICHOM) standard set for cleft care appraisal recommends clinicians assess articulation with percentage consonants correct (PCC) and velopharyngeal function with velopharyngeal competency rating (VPC-R). This study explores the utility and limitations of these generic measures in detecting cleft speech sound disorders by comparing them with two cleft-specific speech-rating systems, cleft audit protocol of speech-augmented Americleft modification (CAPS-A-AM) and Pittsburgh weighted speech scale (PWSS).

Methods

Consecutive children with repaired, nonsyndromic cleft lip/palate, aged 5 years or older (n = 27) underwent prospective speech evaluations conducted at a single academic institution. These evaluations were conducted, recorded, and evaluated by blinded speech-language pathologists experienced with all tools.

Results

When comparing measures of articulation, PCC scores correlated better with scores for relevant subcomponents of CAPS-A-AM than PWSS. When comparing measures of velopharyngeal function, VPC-R scores correlated well with relevant components of both scales. Using a "screening test versus diagnostic test" analogy, VPC-R ratings were 87.5% sensitive and 73.7% specific for detecting velopharyngeal dysfunction according to subcomponents of CAPS-A-AM, and 70.6% sensitive and 100% specific according to subcomponents of PWSS.

Conclusions

This exploratory study demonstrates that PCC and VPC-R perform moderately well in detecting articulatory and velopharyngeal dysfunction in patients with cleft lip/palate; however, these tools cannot describe nuances of cleft speech sound disorder. Thus, although PCC and VPC-R adequately track basic minimum outcomes, we encourage teams to consider extending the standard set by adopting a cleft-specific measurement system for further evaluation of the tools.

Diagnosing and Managing Velopharyngeal Insufficiency in Patients With Cleft Palate After Primary Palatoplasty

Velopharyngeal insufficiency (VPI) after palatoplasty is caused by improper anatomy preventing velopharyngeal closure and manifests as a hypernasal resonance, audible nasal emissions, weak pressure consonants, compensatory articulation, reduced speech loudness, and nostril or facial grimacing. A multidisciplinary team using multimodal instruments (speech analysis, nasoendoscopy, videofluoroscopy, nasometry, and magnetic resonance imaging) to evaluate velopharyngeal function should manage these patients. Careful monitoring of velopharyngeal function by a speech pathologist remains paramount for early identification of VPI and the perceptual assessment should follow a standardized protocol. The greatest methodology problem in CLP studies has been the use of highly variable speech samples making comparison of published results impossible. It is hoped that ongoing international collaborative efforts to standardize procedures for collection and analysis of perceptual data will help this issue. Speech therapy is the mainstay treatment for velopharyngeal mislearning and compensatory articulation, but it cannot improve hypernasality, nasal emissions, or weak pressure consonants, and surgery is the definitive treatment for VPI. Although many surgical methods are available, there is no conclusive data to guide procedure choice. The goal of this review article is to present a review of established diagnostic and management techniques of VPI.

Systematic Review of Postoperative Velopharyngeal Insufficiency: Incidence and Association With Palatoplasty Timing and Technique

Cleft palate is among the most common congenital disorders worldwide and is correctable through surgical intervention. Sub-optimal surgical results may cause velopharyngeal insufficiency (VPI). When symptomatic, VPI can cause hypernasal or unintelligible speech. The postoperative risk of VPI varies significantly in the literature but may be attributed to differences in study size, cleft type, surgical technique, and operative age. To identify the potential impact of these factors, a systematic review was conducted to examine the risk of VPI after primary palatoplasty, accounting for operative age and surgical technique. A search of PubMed, Embase, and Web of Science was completed for original studies that examined speech outcomes after primary palatoplasty. The search identified 4740 original articles and included 35 studies that reported mean age at palatoplasty and VPI-related outcomes. The studies included 10,795 patients with a weighted mean operative age of 15.7 months (range: 3.1-182.9 mo), and 20% (n=2186) had signs of postoperative VPI. Because of the heterogeneity in reporting of surgical technique across studies, small sample sizes, and a lack of statistical power, an analysis of the VPI risk per procedure type and timing was not possible. A lack of data and variable consensus limits our understanding of optimal timing and techniques to reduce VPI occurrence. This paper presents a call-to-action to generate: (1) high-quality research from thoughtfully designed studies; (2) greater global representation; and (3) global consensus informed by high-quality data, to make recommendations on optimal technique and timing for primary palatoplasty to reduce VPI.

Pharyngeal flap in velopharyngeal insufficiency: Proposal of an algorithm in a series of 31 patients

This study evaluated the results of a reproductible protocol indicating the need for a pharyngeal flap in children with cleft palate and velopharyngeal insufficiency (VPI). A retrospective review of all patients operated for a pharyngeal flap between 2010 and 2019 in our center was conducted. After exclusion of patients with primary VPI or residual fistulas, 31 patients' data were analyzed. Our main outcome measure was the improvement of the Borel Maisonny Classification (BMC) by at least 1 rank. Further analysis was made to evaluate the impact of age, type of cleft, and BMC before surgery on the gain in the velopharyngeal function. Of the 31 patients, success was achieved in 29 (93.5%, p<0.005). There was no significant correlation between age and gain in the velopharyngeal function (p = 0.137). There was no significant correlation between type of cleft and gain in the velopharyngeal function (p = 0.148). There was a significant correlation observed between the starting classification and gain in velopharyngeal function. The gain observed was greater as the initial velopharyngeal function was worse (p = 0.035). The use of an algorithm combining clinical assessment with a standardized classification of the velopharyngeal function proved to be a reliable tool for the indication of surgery in patients with VPI. A close follow up is essential in a multidisciplinary team.

Objective and subjective evaluation of Velopharyngeal Dysfunction (VPD) following surgical repair of the cleft palate using the furlow palatoplasty - A new tool

Velopharyngeal dysfunction (VPD) diagnosis and speech surgery outcomes are currently based solely on subjective evaluation criteria consisting of perceptual speech assessment and functional imaging. This study describes an objective and comparable method in VPD assessment and investigates the concurrence between the objective and subjective evaluations. The present study included 20 paediatric patients presenting with VPD after primary repair (intravelar veloplasty) of cleft palate. Our protocol was based on computerized analysis of voice parameters by means of an objective tool, spectrography integrated with Multi-Dimensional Voice Program (MDVP). The protocol also included perceptual evaluation by speech therapist and phoniatrician (consensus listening), and parents. This is a single surgeon, single centre experience and all patients underwent a secondary Furlow's palatoplasty. Assessments were performed pre- and postoperatively and upon completion of speech therapy. Results were compared using the two-tailed t student test for paired data. Statistical significance was set for p-values <0.05. Data analysis confirmed an improvement in velopharyngeal closure after surgery and speech therapy consistently with the results of perceptual evaluations. The results of the study confirmed the availability and reliability of an objective method for VPD evaluation based on the analysis of voice parameters with investigations that are simple and easily available in a hospital setting.

Nasalance Scores for Normal Speakers of American English Obtained by the Nasometer II Using the MacKay-Kummer SNAP-R Test

OBJECTIVE

To establish nasalance score norms for adolescent and young adult native speakers of American English and also determine age-group and gender differences using the Simplified Nasometric Assessment Procedures (SNAP) Test-R and Nasometer II.

DESIGN

Prospective study using a randomly selected sample of participants.

SETTING

Greater Cincinnati area and Miami University of Ohio.

PARTICIPANTS

Participants had a history of normal speech and language development and no history of speech therapy. Participants in the adolescent group were recruited from schools in West Clermont and Hamilton County, whereas the young adults were recruited from Miami University of Ohio. The participants of both groups were residents of Cincinnati, Ohio or Oxford, Ohio and spoke midland American English dialect.

OUTCOME MEASURES

Mean nasalance scores for the SNAP Test-R.

RESULTS

Normative nasalance scores were obtained for the Syllable Repetition/Prolonged Sounds, Picture-Cued, and Paragraph subtests. Results showed statistically significant nasalance score differences between adolescents and young adults in the Syllable Repetition, Picture-Cued, and Paragraph subtests, and between males and females in the Syllable Repetition and the Sound-Prolonged subtests. A significant univariate effect was found for the syllables and sentences containing nasal consonants and high vowels compared to syllables and sentences containing oral consonants and low vowels. Across all the SNAP Test-R subtests, the females' nasalance scores were higher than the males. A significant univariate effect was also found across nasal syllables, and high vowels such that the females' nasalance scores were higher than the males. Tables of normative data are provided that may be useful for clinical purposes.

CONCLUSION

Norms obtained demonstrated nasalance score differences according to age and gender, particularly in the Syllable Repetition/Prolonged Sound subtest. These differences were discussed in light of potential reasons for their existence and implications for understanding velopharyngeal function. In addition, nasalance scores are affected by the vowel type and place of articulation of the consonant. These facts should be considered when nasometry is used clinically and for research purposes.

Optimal Outcomes Reporting (OOR): A New Value-Based Metric for Outcome Reporting Following Cleft Palate Repair

OBJECTIVE

Palatoplasty outcome measurements vary widely among institutions. A standardized outcome metric would help provide quality benchmarks.

DESIGN

Retrospective review of primary palatoplasty patients from 2007 to 2013.

SETTING

Tertiary care children's hospital.

MAIN OUTCOME MEASURES

We created a novel conceptual quality metric called "OOR" (Optimal Outcome Reporting). Optimal Outcome Reporting is designed to reflect the percentage of patients with cleft palate who experience the best outcomes: one operation, velar competence by age 5 years, and no unintended palatal fistula.

RESULTS

Optimal Outcome Reporting was 72.3% (68/94). Eight patients had "suboptimal" outcomes for having undergone more than one operation. Eighteen patients failed for velar incompetence. No additional patients fell out of the algorithm for fistula. A significantly higher proportion of nonsyndromic patients demonstrated an "optimal" result compared to syndromic patients (61/80, 76.3% vs 7/14, 50.0%; P = .04). Patients who required more than one procedure had significantly more clinic visits (32.6 vs 14.9; P < .01) and accrued higher costs compared to "optimal" patients (US$34 019.88 vs US$15 357.25; P < .01).

CONCLUSIONS

Optimal Outcome Reporting represents a novel quality metric that can provide meaningful information for patients with cleft palate. Optimal Outcome Reporting utilization can help cleft centers adopt changes that matter to patients and their families. By allowing for cross-institutional comparisons in a clear and objective manner, OOR can promote competition, innovation, and value in cleft palate care.

PATTERN OF SPEECH ARTICULATION ERRORS IN NIGERIAN INDIVIDUALS WITH CLEFT LIP AND OR PALATE ANOMALIES FOLLOWING REPAIR

The occurrence of cleft lip and palate anomaly can impact on an affected individual's quality of life. Cleft of the palate particularly significantly affects the production of speech. This article aims to describe the speech errors following palatoplasty procedures observed from cleft centres within Nigeria. Ability to produce high pressure sounds, frequencies of speech errors and speech intelligibility were analysed from data collated from five cleft centres. The speech services in these centres were provided in partnership with Smile Train, a nongovernmental organization based in the United States of America. Glottal stop was the commonest speech error while the speech intelligibility was considered mild in the majority of cases. This report serves as a form of preliminary overview of the speech pattern of individuals with repaired cleft palate in our environment.

Measuring Patient-Reported Health-Related Quality of Life in Velopharyngeal Insufficiency: Reliability and Validity of the Brazilian Portuguese Version of the VELO Instrument

OBJECTIVE

To test the Brazilian Portuguese velopharyngeal insufficiency (VPI) Effects on Life Outcome (VELO) instrument for reliability and validity.

DESIGN

Cross-sectional methodological study.

SETTING

Tertiary craniofacial medical center.

PARTICIPANTS

Participants with VPI (VPI group, n = 60), with cleft and without VPI (no VPI/cleft group, n = 60), and with no cleft nor VPI (no VPI/no cleft group, n = 60) and their parents (n = 180).

INTERVENTIONS

All patients with VPI 8+ years old and their parents completed the Brazilian-Portuguese VELO instrument and other questionnaires (Pediatric Quality of Life Inventory4.0, PedsQL4.0; Pediatric Voice-Related Quality of Life, PVRQOL; and Intelligibility in Context Scale, ICS) at baseline; patients with VPI and their parents completed the VELO instrument again 2 weeks later.

MAIN OUTCOME MEASURES

The VELO instrument was tested for internal consistency, test-retest reliability, discriminant validity (participants with VPI against participants with no VPI), concurrent validity against other questionnaires, criterion validity against hypernasality severity, and construct validity against nasal air emission and overall velopharyngeal competence (speech construct) and velopharyngeal gap (anatomic construct).

RESULTS

The VELO had excellent internal consistency (Cronbach α 0.99 for parents and 0.98 for participants with VPI) and test-retest reliability (all intraclass correlation coefficient > 0.87). The VELO discriminated well between VPI group and unaffected groups (all P < .05). The VELO was significantly correlated with the PedsQL^4.0, PVRQOL, and ICS (-r > 0.75; P < .001). The VELO met criterion validity, speech construct validity, and anatomic construct validity (r > 0.7; P < .001).

CONCLUSIONS

The Brazilian-Portuguese VELO instrument demonstrated reliability (internal consistency and test-retest) and validity (discriminant, concurrent, criterion, and construct).