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

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.

Timing of Primary Surgery for Cleft Palate

BACKGROUND

Among infants with isolated cleft palate, whether primary surgery at 6 months of age is more beneficial than surgery at 12 months of age with respect to speech outcomes, hearing outcomes, dentofacial development, and safety is unknown.

METHODS

We randomly assigned infants with nonsyndromic isolated cleft palate, in a 1:1 ratio, to undergo standardized primary surgery at 6 months of age (6-month group) or at 12 months of age (12-month group) for closure of the cleft. Standardized assessments of quality-checked video and audio recordings at 1, 3, and 5 years of age were performed independently by speech and language therapists who were unaware of the trial-group assignments. The primary outcome was velopharyngeal insufficiency at 5 years of age, defined as a velopharyngeal composite summary score of at least 4 (scores range from 0 to 6, with higher scores indicating greater severity). Secondary outcomes included speech development, postoperative complications, hearing sensitivity, dentofacial development, and growth.

RESULTS

We randomly assigned 558 infants at 23 centers across Europe and South America to undergo surgery at 6 months of age (281 infants) or at 12 months of age (277 infants). Speech recordings from 235 infants (83.6%) in the 6-month group and 226 (81.6%) in the 12-month group were analyzable. Insufficient velopharyngeal function at 5 years of age was observed in 21 of 235 infants (8.9%) in the 6-month group as compared with 34 of 226 (15.0%) in the 12-month group (risk ratio, 0.59; 95% confidence interval, 0.36 to 0.99; P = 0.04). Postoperative complications were infrequent and similar in the 6-month and 12-month groups. Four serious adverse events were reported (three in the 6-month group and one in the 12-month group) and had resolved at follow-up.

CONCLUSIONS

Medically fit infants who underwent primary surgery for isolated cleft palate in adequately resourced settings at 6 months of age were less likely to have velopharyngeal insufficiency at the age of 5 years than those who had surgery at 12 months of age. (Funded by the National Institute of Dental and Craniofacial Research; TOPS ClinicalTrials.gov number, NCT00993551.).

Agreements between speech language pathologists and naïve listeners' judgements of intelligibility in children with cleft palate

Speech-language pathologists (SLPs) working in interdisciplinary craniofacial teams need to know how much their judgments of speech intelligibility could predict the patient's communication difficulties with non-clinical communicative partners. This study examines the relationship between experienced SLPs and naïve listeners in judgments of speech intelligibility in speakers with cleft palate. A speech perception study was conducted using speech samples from 20 speakers with velopharyngeal insufficiency (VPI) following cleft palate. Speech samples were presented to 70 naïve listeners and 10 SLPs who were experts in cleft palate treatment. Speech intelligibility scores from naïve listeners' orthographic transcriptions were obtained as the percentage of correctly identified words. Speech intelligibility scores from SLPs were obtained using a five-point rating scale. Spearman rank correlation indicated a very high level of overall agreement between naïve listeners and SLPs at the speaker level scores (r_s = -.94, p < .001). While the listeners' judgment seems highly related across highly intelligible speakers, the differences in agreements increase when the speaker is unintelligible. The high correlations between scores for naïve listeners and SLPs suggest that speech intelligibility in children with VPI could be predicted by ratings done in the clinic by expert SLPs.

Compensatory Articulation Errors in Patients With Velopharyngeal Dysfunction and Palatal Anomalies

PURPOSE

The aim of this study was to assess the frequency and types of compensatory articulations (CAs) in nonsyndromic patients with velopharyngeal dysfunction (VPD) and various palatal anomalies and to determine the relationship between the frequency of CAs, type of palatal anomaly, and phonological errors.

METHOD

A total of 783 nonsyndromic, Hebrew-speaking patients with VPD and various palatal anomalies (cleft lip and palate [CLP], cleft palate [CP], submucous CP [SMCP], occult submucous CP [OSMCP], or non-CP) were studied retrospectively. Perceptual VPD tests, including articulation and phonological assessment, were conducted. CAs were described as below the level of the defect in the vocal tract (abnormal backing of oral targets to post-uvular place) or in front of it within the oral cavity (palatalization) and at the velopharyngeal port.

RESULTS

Among 783 patients, 213 (27.2%) had CAs. Most CAs (18.4%) occurred below the level of the defect, followed by CAs at the velopharyngeal port (12.0%) or in front of it (4.9%). No differences were found in the frequency of CAs between patients with CP (47.8%) or CLP (52.6%) and between those with non-CP (13.6%) or OSMCP (14.7%). SMCP patients had lower frequency of CAs (29.8%) than CP (p = .003) and CLP (p =  .002) patients but higher frequency than OSMCP (p = .002) and non-CP (p =  .002) patients did. Among the 783 patients, 247 (31.5%) had phonological errors. A higher frequency of phonological errors was found in patients with CAs (55.4%) compared to those without (22.6%) and in all palatal anomaly groups except CLP (31.4% vs. 23.9%).

CONCLUSIONS

CAs in nonsyndromic patients with VPD remained relatively high in all age groups, up to adulthood. CAs are influenced by inadequate velar length following palatal repair, as well as by oral structural abnormalities, whereas poor muscle function due to OSMCP and/or abnormal size and/or shape of nasopharynx has less influence. Errors produced in front of the velopharyngeal port are influenced by the structural anomaly of CLP. This information may contribute to general phonetic and phonological theories and genetic investigations about CP anomalies.

On the Benefits of Speech-Language Therapy for Individuals Born With Cleft Palate: A Systematic Review and Meta-Analysis of Individual Participant Data

PURPOSE

Cleft lip and/or palate (CLP) is a common birth defect, and after reconstructive surgery, about 50% of children at 5 years of age have speech deviations and are referred to speech-language therapy (SLT). The peer-reviewed evidence for the benefit of SLT has been uncertain. Our objective was to systematically review and meta-analytically summarize the benefit of SLT for individuals born with CLP.

METHOD

A systematic search was conducted (last search on February 19, 2021) on studies evaluating SLT with pre and post measures on speech production, language ability, intelligibility, and/or patient-reported outcomes. We sought individual participant data (IPD) and evaluated on an individual level if the outcome measure had improved to a clinically relevant degree during SLT and if the outcome measure was on a level with peers or not after SLT. Meta-analyses and meta-regressions were applied to synthesize IPD across studies.

RESULTS

Thirty-four eligible studies were found. Nineteen studies provided IPD (n = 343) for the main analysis on speech production. The synthesized information suggests that, during SLT, speech production improved to a clinically relevant degree for many individuals (95% CI [61%, 87%]) and that speech production was on a level with peers for some individuals after SLT (95% CI [10%, 34%]).

CONCLUSIONS

The main strength of this meta-analysis is that we evaluated on an individual level pre- and post-intervention data based on considerations of clinical relevance. This approach allowed us to conclude that many individuals benefit from SLT and that further work on evaluating SLT in this patient group is meaningful. Supplemental Material https://doi.org/10.23641/asha.17700992.

Benchmarking Speech, Velopharyngeal Function Outcomes and Surgical Characteristics Following the Sommerlad Protocol and Palate Repair Technique

Objective:

To report speech and velopharyngeal function (VPF) outcomes, and surgical characteristics, at age 5 following early complete palate closure using the Sommerlad protocol.

Design:

A retrospective, descriptive, cross-sectional consecutive series.

Setting:

A regional twin site center; a district general hospital and tertiary children’s hospital.

Participants:

Between 1993 and 2006, 877 participants underwent surgery; 712 (81%) were eligible for inclusion; 391 (55%) were included, 321 (45%) excluded. Thirteen percent had bilateral cleft lip and palate (CLP), 40% unilateral CLP, and 47% isolated cleft palate.

Intervention:

Lip and vomerine flap repair at 3 months of age (BCLP, UCLP) with soft palate closure using radical muscle dissection and retropositioning at a mean age of 6.6 months, range 4 to 23 months, as described and undertaken by Sommerlad.

Outcome Measures:

Velopharyngeal Composite (VPC) CAPS-A and articulation summary scores derived from analysis using the Cleft Audit Protocol for Speech-Augmented.

Results:

A VPC-SUM CAPS-A score of “0” was found in 97% reflecting adequate VPF; 73% had no cleft articulation difficulties. The BCLP group had the poorest articulation. Secondary speech surgery rate was 2.6% and 10.7% had fistula repair. Levator muscle quality and degree of retropositioning was associated with speech outcomes related to VPF. 2.6% had current features of VPI.

Conclusions:

Complete palate closure by around 6 months of age by the surgeon who described the technique led to excellent perceived VPF and very good speech outcomes at age 5, with less speech therapy and secondary speech surgery than commonly reported. These findings serve as a benchmark for the Sommerlad protocol and technique.

Scandcleft Project Trial 3: Comparison of Speech Outcomes in Relation to Sequence in 2-Stage Palatal Repair Procedures in 5-Year-Olds With Unilateral Cleft Lip and Palate

OBJECTIVE

To compare speech outcome following different sequencing of hard and soft palate closure between arms and centers within trial 3 and compare results to peers without cleft palate.

DESIGN

A prospective randomized clinical trial.

SETTING

Two Norwegian and 2 British centers.

PARTICIPANTS

One hundred thirty-six 5-year-olds with unilateral cleft lip and palate were randomized to either lip and soft palate closure at 3 to 4 months and hard palate closure at 12 months (arm A) or lip and hard palate closure at 3 to 4 months and soft palate closure at 12 months (arm D).

MAIN OUTCOME MEASURES

A composite measure of velopharyngeal competence (VPC), overall assessment of VPC from connected speech (VPC-Rate). Percentage of consonants correct (PCC), active cleft speech characteristics (CSCs), subdivided by oral retracted and nonoral errors, and developmental speech characteristics (DSCs).

RESULTS

Across the trial, 47% had VPC, with no statistically significant difference between arms within or across centers. Thirty-eight percent achieved a PCC score of >90%, with no difference between arms or centers. In one center, significantly more children in arm A produced ≥3 active CSCs (P < .05). Across centers, there was a statistically significant difference in active CSCs (arm D), oral retracted CSCs (arm D), and DSCs (arms A and D).

CONCLUSIONS

Less than half of the 5-year-olds achieved VPC and around one-third achieved age-appropriate PCC scores. Cleft speech characteristics were more common in arm A, but outcomes varied within and across centers. Thus, outcome of the same surgical method can vary substantially across centers.

Scandcleft Project Trial 2-Comparison of Speech Outcome in 1- and 2-Stage Palatal Closure in 5-Year-Olds With UCLP

OBJECTIVE

To investigate in-depth speech results in the Scandcleft Trial 2 with comparisons between surgical protocols and centers and with benchmarks from peers without cleft palate.

DESIGN

A prospective randomized clinical trial.

SETTING

Two Swedish and one Finnish Cleft Palate center.

PARTICIPANTS

One hundred twelve participants were 5-years-old born with unilateral cleft lip and palate randomized to either lip repair and soft palate closure at 4 months and hard palate closure at 12 months or lip repair at 3 to 4 months (Arm A), or a closure of both the soft and hard palate at 12 months (Arm C).

MAIN OUTCOME MEASURES

A composite measure dichotomized into velopharyngeal competency (VPC) or velopharyngeal incompetency (VPI), overall assessment of velopharyngeal function (VPC-Rate), percentage of consonants correct (PCC score), and consonant errors. In addition, number of speech therapy visits, average hearing thresholds, and secondary surgeries were documented to assess burden of treatment.

RESULTS

Across the trial, 53.5% demonstrated VPC and 46.5% VPI with no significant differences between arms or centers. In total, 27% reached age-appropriate PCC scores with no statistically significant difference between the arms. The Finnish center had significantly higher PCC scores, the Swedish centers had higher percentages of oral consonant errors. Number of speech therapy visits was significantly higher in the Finnish center.

CONCLUSION

At age 5, poor speech outcomes with some differences between participating centers were seen but could not be attributed to surgical protocol. As one center had very few participants, the results from that center should be interpreted with caution.

Development of a method for assessment of dysarthria in a foreign language: a pilot study

Purpose: It is increasingly more common for Speech and Language Pathologists in Sweden to encounter individuals with dysarthria who speak a different language. The aim of the present pilot study was to develop and test a systematic method to be used in collaboration with an interpreter, for assessment of acquired dysarthria in people speaking a language not familiar to the Speech and Language Pathologist.Methods: Seven participants, speaking standard Arabic, were assessed by a Swedish speaking Speech and Language Pathologist using this method and with help of a certified interpreter. The participants were also assessed with equivalent test items from the Swedish "Dysarthria assessment," with instructions translated to Arabic, by a Speech and Language Pathologist speaking standard Arabic and the results were compared.Results: There were no significant differences between the assessments by the Swedish speaking Speech and Language Pathologist and the Arabic speaking Speech and Language Pathologist in the domains "Respiration and phonation," "Articulation," "Listener Comprehension" and "Severity of dysarthria." There was a significant difference between assessments in the domain "Oromotor and velopharyngeal function." Intra- and inter-rater reliability was also calculated using Intraclass Correlation Coefficient and their 95% Confidence Interval. Intra-rater reliability was excellent and inter-rater reliability was very good.Conclusion: The study indicates that a Speech and Language Pathologist, with help of an interpreter, can carry out an assessment of dysarthria in a language unknown to the Speech and Language Pathologist with results comparable to results from an assessment carried out by a Speech and Language Pathologist who speaks the foreign language.

Stages in the Development and Validation of a Belgian Dutch Outcome Tool for the Perceptual Evaluation of Speech in Patients With Cleft Palate

Objective:

To develop and validate a Belgian Dutch outcome tool for the perceptual evaluation of speech in patients with cleft palate.

Setting:

Cleft palate team in a tertiary university hospital.

Methods:

The tool was based on the Cleft Audit Protocol for Speech–Augmented (John et al., 2006; Sell et al., 2009), with adaptations to some of the speech variables and the structured listening protocol. Following a preliminary listening experiment in phase 1, the tool was optimized. In the second phase, a listening experiment with 4 experienced listeners was set up to assess face validity, inter- and intrarater reliability and criterion validity.

Results:

Results of phase 1 indicated good to very good inter- and intrarater reliability for the majority of the speech variables, good discriminant validity, and varying sensitivity and specificity based on a comparison with nasalance values and the Nasality Severity Index 2.0 (criterion validity). Results of phase 2 showed good to very good interrater reliability for 5 of the 14 variables and good intrarater reliability in 3 of the 4 experienced listeners. Sensitivity and specificity were sufficient, except the specificity of the hypernasality judgments in comparison with the nasalance values of the oral text. Overall, listeners positively judged the face validity of the tool.

Conclusion:

The 2-phase evaluation indicated varying validity and reliability results. Future studies will aim to optimize validity and reliability of the developed tool based on adaptations to the listening protocol, the addition of speech variables, and the inclusion of a more elaborate training.

Perceptual evaluation of hypernasality, audible nasal airflow and speech understandability using ordinal and visual analogue scaling and their relation with nasalance scores

PURPOSE

Perceptual assessments remain the most commonly utilized procedure to diagnose and evaluate resonance disorders. However, the discussion continues about which rating scale has to be applied. Therefore, this study aimed to compare the reliability and validity of ordinal and visual analogue scales to rate hypernasality, audible nasal airflow and speech understandability.

METHODS

Four experienced speech-language pathologists rated 35 speech samples of children with a range of hypernasality, audible nasal airflow and speech understandability, using an ordinal scale and a visual analogue scale. Intraclass correlations coefficients determined intra- and inter-rater reliability. The model of best fit was determined by plotting both rating scales against each other. A Pearson correlation coefficient verified the relationship between both rating scales and nasalance scores determined by a Nasometer.

RESULTS

Good intra- and inter-rater reliability was found for both rating scales. A multiple regression analysis revealed a curvilinear relationship between both rating scales, indicating a slight preference to rate all parameters by a visual analogue scale. Comparable correlations with nasalance scores were found.

CONCLUSIONS

This study confirms that visual analogue scale ratings form a reliable and valid alternative for ordinal ratings in the perceptual judgments of hypernasality, audible nasal airflow and speech understandability. A combination of both rating scales may even combine the advantages and eliminate their limitations. However, further research is necessary to verify how this new approach can be implemented in available protocols for clinical practice, audits and research.

Reliability of Hypernasality Rating

Objective:

To compare reliability in auditory-perceptual assessment of hypernasality for 3 different methods and to explore the influence of language background.

Design:

Comparative methodological study.

Participants and Materials:

Audio recordings of 5-year-old Swedish-speaking children with repaired cleft lip and palate consisting of 73 stimuli of 9 nonnasal single-word strings in 3 different randomized orders. Four experienced speech-language pathologists (2 native speakers of Brazilian–Portuguese and 2 native speakers of Swedish) participated as listeners. After individual training, each listener performed the hypernasality rating task. Each order of stimuli was analyzed individually using the 2-step, VISOR and Borg centiMax scale methods.

Main Outcome Measures:

Comparison of intra- and inter-rater reliability, and consistency  for each method within language of the listener and between listener languages (Swedish and Brazilian–Portuguese).

Results:

Good to excellent intra-rater reliability was found within each listener for all methods, 2-step: κ = 0.59-0.93; VISOR: intraclass correlation coefficient (ICC) = 0.80-0.99; Borg centiMax (cM) scale: ICC = 0.80-1.00. The highest inter-rater reliability was demonstrated for VISOR (ICC = 0.60-0.90) and Borg cM-scale (ICC = 0.40-0.80). High consistency within each method was found with the highest for the Borg cM scale (ICC = 0.89-0.91). There was a significant difference in the ratings between the Swedish and the Brazilian listeners for all methods.

Conclusions:

The category-ratio scale Borg cM was considered most reliable in the assessment of hypernasality. Language background of Brazilian–Portuguese listeners influenced the perceptual ratings of hypernasality in Swedish speech samples, despite their experience in perceptual assessment of cleft palate speech disorders.

Influence of timing of delayed hard palate closure on articulation skills in 3-year-old Danish children with unilateral cleft lip and palate

BACKGROUND

Differing results regarding articulation skills in young children with cleft palate (CP) have been reported and often interpreted as a consequence of different surgical protocols.

AIMS

To assess the influence of different timing of hard palate closure in a two-stage procedure on articulation skills in 3-year-olds born with unilateral cleft lip and palate (UCLP). Secondary aims were to compare results with peers without CP, and to investigate if there are gender differences in articulation skills. Furthermore, burden of treatment was to be estimated in terms of secondary surgery, hearing and speech therapy.

METHODS & PROCEDURES

A randomized controlled trial (RCT). Early hard palate closure (EHPC) at 12 months versus late hard palate closure (LHPC) at 36 months in a two-stage procedure was tested in a cohort of 126 Danish-speaking children born with non-syndromic UCLP. All participants had the lip and soft palate closed around 4 months of age. Audio and video recordings of a naming test were available from 113 children (32 girls and 81 boys) and were transcribed phonetically. Recordings were obtained prior to hard palate closure in the LHPC group. The main outcome measures were percentage consonants correct adjusted (PCC-A) and consonant errors from blinded assessments. Results from 36 Danish-speaking children without CP obtained previously by Willadsen in 2012 were used for comparison.

OUTCOMES & RESULTS

Children with EHPC produced significantly more target consonants correctly (83%) than children with LHPC (48%; p < .001). In addition, children with LHPC produced significantly more active cleft speech characteristics than children with EHPC (p < .001). Boys achieved significantly lower PCC-A scores than girls (p = .04) and produced significantly more consonant errors than girls (p = .02). No significant differences were found between groups regarding burden of treatment. The control group performed significantly better than the EHPC and LHPC groups on all compared variables.

Speech Intelligibility of Patients with Cleft Lip and Palate after Placement of Speech Prosthesis

Objective:

To evaluate the speech intelligibility of patients with clefts before and after placement of a speech prosthesis.

Design:

Cross-sectional.

Setting:

Hospital for Rehabilitation of Craniofacial Anomalies, University of São Paulo (HRAC/USP), Bauru, Brazil.

Patients:

Twenty-seven patients with unoperated cleft palate or operated cleft palate presenting with velopharyngeal insufficiency (VPI) after primary palatoplasty, treated with speech prosthesis, aged 8 to 63 years.

Interventions:

Patients were fitted with palatopharyngeal obturators or pharyngeal bulbs, suitable to their dental needs. Five speech-language pathologists blindly evaluated speech samples of the patients with and without the prosthesis.

Main Outcome Measures:

Classification of speech samples according to a scoring system developed for speech intelligibility problems: 1 (normal), 2 (mild), 3 (mild to moderate), 4 (moderate), 5 (moderate to severe), and 6 (severe). Results were evaluated by the calculation of means of all judges for each patient in both situations.

Results:

The judges presented significant agreement (W = .789, p < .01). Speech intelligibility was significantly better after placement of the prosthesis for both unoperated patients (Z = 1.93, p = .02) and operated patients with VPI after primary palatoplasty (Z = 1.78, p = .03).

Conclusions:

Speech intelligibility may be improved by rehabilitation of patients with cleft palate using a speech prosthesis. Speech therapy is needed to eliminate any compensatory articulation productions developed prior to prosthetic management.

Phonetic Description of Babbling in Danish Toddlers Born with and without Unilateral Cleft Lip and Palate

Objective

To investigate prelinguistic vocalization sequences of 1-year-old children with and without cleft lip and palate.

Design

Prospective study.

Participants

Thirty-eight children born with unilateral cleft lip and palate and 36 control children born without clefts. The cleft children had the lip, soft palate, and posterior part of the hard palate repaired at 4 months of age. The lip was closed ad modum Millard, the nose was corrected according to McComb, and the soft palate was closed with a posteriorly based vomer flap.

Methods

Data were obtained from a clinical visit during which the baby played with the mother. Video recordings were transcribed and analyzed concerning (1) the frequency of occurrence of vocalization sequences, (2) the frequency of occurrence of contoids and vocoids, (3) the contoids’ place and manner of articulation, and (4) the percentage of children who entered the canonical babbling stage.

Results

No significant differences were observed between the cleft and control groups concerning frequency of occurrence of vocalization sequences, contoids, or vocoids. Structural differences between the groups seem to influence the contoid inventory, with a higher frequency of occurrence of nasal contoids and a smaller frequency of occurrence of alveolar contoids in the cleft group. Canonical babbling was achieved by most children in both groups, and no significant difference was found between the groups.

Conclusions

Early closure of the soft palate seems to have a positive influence on the prelinguistic development of children with cleft palate.

Scandcleft randomised trials of primary surgery for unilateral cleft lip and palate: 5. Speech outcomes in 5-year-olds - consonant proficiency and errors

BACKGROUND AND AIM

Normal articulation before school start is a main objective in cleft palate treatment. The aim was to investigate if differences exist in consonant proficiency at age 5 years between children with unilateral cleft lip and palate (UCLP) randomised to different surgical protocols for primary palatal repair. A secondary aim was to estimate burden of care in terms of received additional secondary surgeries and speech therapy.

DESIGN

Three parallel group, randomised clinical trials were undertaken as an international multicentre study by 10 cleft teams in five countries: Denmark, Finland, Norway, Sweden, and the UK.

METHODS

Three different surgical protocols for primary palatal repair were tested against a common procedure in the total cohort of 448 children born with non-syndromic UCLP. Speech audio- and video-recordings of 391 children (136 girls and 255 boys) were available and transcribed phonetically. The main outcome measure was Percent Consonants Correct (PCC) from blinded assessments.

RESULTS

In Trial 1, arm A showed statistically significant higher PCC scores (82%) than arm B (78%) (p = .045). No significant differences were found between prevalences in Trial 2, A: 79%, C: 82%; or Trial 3, A: 80%, D: 85%. Across all trials, girls achieved better PCC scores, excluding s-errors, than boys (91.0% and 87.5%, respectively) (p = .01).

CONCLUSIONS

PCC scores were higher in arm A than B in Trial 1, whereas no differences were found between arms in Trials 2 or 3. The burden of care in terms of secondary pharyngeal surgeries, number of fistulae, and speech therapy visits differed.

TRIAL REGISTRATION

ISRCTN29932826.

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.

A non-language-specific speech test to evaluate the speech of cleft patients from different language and cultural backgrounds - A pilot study

Cleft speech tests are not universally available. We developed a tool to fill this gap, especially in the context of a cleft mission setting. We performed a pilot study to evaluate the test's ability to differentiate between the speech of cleft patients and healthy individuals from three different language backgrounds. We used 78 made-up, nonsensical syllables to evaluate hypernasality, nasal emissions, and consonant errors. Cleft (n = 41) and non-cleft (n = 39) individuals from three countries were included in this study. Two speech and language pathologists, blinded to the examination, rated the audio recording independently. Patients from Germany (n = 12; mean age 15.2), Iran (n = 14; mean age 7), and India (n = 15; mean age 14.7 years) were evaluated. We observed a significant difference in each category (p < 0.05) between patients and control subjects of the same language and cultural background. Hypernasality was affected the most. The test proved to possess the correct phonetic characteristics to reveal and provoke relevant cleft speech pathologies independent of cultural and language backgrounds. The test sounds posed no articulatory difficulties to non-cleft individuals, with some exceptions regarding non-specific consonant errors. A comparison with other existing tests will further illuminate its value as a speech test.

Delayed primary palatal closure in resource-poor countries: Speech results in Ugandan older children and young adults with cleft (lip and) palate

AIMS

Unrepaired clefts still regularly occur in resource-poor countries as a result of limited health-care access. The purpose of the present study was to report resonance, airflow and articulation characteristics following delayed (≥8years) primary palatal closure.

METHODS

Fifteen Ugandan participants with cleft (lip and) palate (CP±L) were included as well as 15 age- and gender-matched Ugandan subjects without clefts. Palatal closure was performed at a mean age of 15;10 years using the Sommerlad technique. Speech evaluations were carried out on a single occasion postoperatively (mean age: 18;10 years). Resonance and nasal airflow were perceptually evaluated and detailed phonetic and phonological assessments were carried out. Additionally, nasalance values were determined.

RESULTS

Nasal emission occurred postoperatively in only 27% (4/15) of the patients, whereas resonance disorders and articulation errors were prevalent in 87% (13/15) of the patient group. Compared with the control group, a significantly higher prevalence of hypernasality and significantly higher nasalance values for all oral and oronasal speech samples were obtained in the CP±L group. Moreover, significantly smaller consonant inventories and significantly more phonetic and phonological disorders were observed.

CONCLUSIONS

Delayed palatal repair (≥8years) seems to be insufficient to eliminate nasal airflow errors, resonance abnormalities, and articulation disorders. In order to prevent patients' late presentation at specialized centers, the availability of high quality surgical cleft palate treatment should increase as well as people's awareness of the possibility and importance of early surgical intervention. Moreover, speech therapy following delayed palatal closure would be beneficial. Furthermore, a standardized and validated protocol for speech assessment in future studies is advocated.

A Standard Set of Outcome Measures for the Comprehensive Appraisal of Cleft Care

Care of the patient with cleft lip and/or palate remains complex. Prior attempts at aggregating data to study the effectiveness of specific interventions or overall treatment protocols have been hindered by a lack of data standards. There exists a critical need to better define the outcomes- particularly those that matter most to patients and their families-and to standardize the methods by which these outcomes will be measured. This report summarizes the recommendations of an international, multidisciplinary working group with regard to which outcomes a typical cleft team could track, how those outcomes could be measured and recorded, and what strategies may be employed to sustainably implement a system for prospective data collection. It is only by agreeing on a common, standard set of outcome measures for the comprehensive appraisal of cleft care that intercenter comparisons can become possible. This is important for quality-improvement endeavors, comparative effectiveness research, and value-based health-care reform.

SVANTE - The Swedish Articulation and Nasality Test - Normative data and a minimum standard set for cross-linguistic comparison

Normative language-based data are important for comparing speech performances of clinical groups. The Swedish Articulation and Nasality Test (SVANTE) was developed to enable a detailed speech assessment. This study's aim was to present normative data on articulation and nasality in Swedish speakers. Single word production, sentence repetition and connected speech were collected using SVANTE in 443 individuals. Mean (SD) and prevalences in the groups of 3-, 5-, 7-, 10-, 16- and 19-year-olds were calculated from phonetic transcriptions or ordinal rating. For the 3- and 5-year-olds, a consonant inventory was also determined. The mean percent of oral consonants correct ranged from 77% at age 3 to 99% at age 19. At age 5, a mean of 96% was already reached, and the consonant inventory was established except for /s/, /r/, /ɕ/. The norms on the SVANTE, also including a short version, will be useful in the interpretation of speech outcomes.

Voice onset time of alveolar stop /t/ and realization of unaspirated affricates associated with Mandarin-speaking children with repaired cleft palate

PURPOSE

To examine perceptually the realization of unaspirated affricates and voice onset time (VOT) features of /t/ in Mandarin-speaking children with repaired cleft palate, and to explore the difficulties associated with unaspirated affricate production from the perspective of the VOT of /t/.

METHOD

Twenty-three children with repaired cleft palate and 22 age-matched typical native Mandarin speakers were recruited. Speakers with cleft palate were allocated into two groups based on expert perceptual judgment of nasality: one group with perceived normal resonance (PNR) (n = 14, average age = 9.3 years), and another group with perceived hypernasal resonance (PHR) (n = 9, average age = 10.3 years).

INTERVENTION

Stimuli were collected through a series of picture naming tasks, targeting the production of initial consonants /t/ and three unaspirated Mandarin affricates /ts, tʂ, tɕ/. The productions of each affricate were evaluated by two experienced speech therapists. The VOT of /t/ was measured using PRAAT speech analysis software.

RESULT

The majority of unaspirated affricates were omitted and/or weakly realized by the group of PHR speakers, but not for the PNR group. A significantly smaller mean VOT value associated with /t/ was identified for the PHR group, as compared to the PNR group. A group difference for VOT value was not found between the PNR group and the typical control group.

CONCLUSION

The voicing features of /t/ and omitted/weak realization of unaspirated affricates identified in the PHR group indicated that the deviant production of unaspirated affricates in the cleft palate group could be associated with the voicing characteristics of the alveolar stop /t/, and this merits further investigation.

Short-term effect of short, intensive speech therapy on articulation and resonance in Ugandan patients with cleft (lip and) palate

OBJECTIVES

The purpose of the current study was to assess the short-term effectiveness of short and intensive speech therapy provided to patients with cleft (lip and) palate (C(L)P) in terms of articulation and resonance.

METHODS

Five Ugandan patients (age: 7.3-19.6 years) with non-syndromic C(L)P received six hours of individualized speech therapy in three to four days. Speech therapy focused on correct phonetic placement and contrasts between oral and nasal airflow and resonance. Speech evaluations performed before and immediately after speech therapy, including perceptual and instrumental assessment techniques, were compared.

RESULTS

Post-therapy, improvement of speech was noted for most of the patients, although to varying degrees. Clinically relevant progress of objective nasalance values and/or articulation was obtained in four patients. Overall, two patients showed normal speech intelligibility, while three patients required additional speech therapy.

CONCLUSION

These preliminary short-term results demonstrate that short and intensive speech therapy can be effective for patients with C(L)P in countries with limited access to speech-language therapy. However, further research is needed on the long-term effectiveness and the advantages of applying this treatment protocol in countries with good access to speech therapy.

LEARNING OUTCOMES

The reader will be able to (1) list the challenges in resource poor-countries to achieve access to speech-language therapy services, (2) describe when the application of speech therapy is appropriate in patients with C(L)P, (3) describe the speech therapy that can be applied to reduce compensatory articulation and resonance disorders in patients with C(L)P, and (4) list the (possible) advantages of short, intensive speech therapy for both resource-poor and developed countries.

The Americleft Speech Project: A Training and Reliability Study

OBJECTIVE

To describe the results of two reliability studies and to assess the effect of training on interrater reliability scores.

DESIGN

The first study (1) examined interrater and intrarater reliability scores (weighted and unweighted kappas) and (2) compared interrater reliability scores before and after training on the use of the Cleft Audit Protocol for Speech-Augmented (CAPS-A) with British English-speaking children. The second study examined interrater and intrarater reliability on a modified version of the CAPS-A (CAPS-A Americleft Modification) with American and Canadian English-speaking children. Finally, comparisons were made between the interrater and intrarater reliability scores obtained for Study 1 and Study 2.

PARTICIPANTS

The participants were speech-language pathologists from the Americleft Speech Project.

RESULTS

In Study 1, interrater reliability scores improved for 6 of the 13 parameters following training on the CAPS-A protocol. Comparison of the reliability results for the two studies indicated lower scores for Study 2 compared with Study 1. However, this appeared to be an artifact of the kappa statistic that occurred due to insufficient variability in the reliability samples for Study 2. When percent agreement scores were also calculated, the ratings appeared similar across Study 1 and Study 2.

CONCLUSION

The findings of this study suggested that improvements in interrater reliability could be obtained following a program of systematic training. However, improvements were not uniform across all parameters. Acceptable levels of reliability were achieved for those parameters most important for evaluation of velopharyngeal function.

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).

Consonant accuracy in Mandarin-speaking children with repaired cleft palate

OBJECTIVE

To compare the consonant production of Chinese-speaking cleft palate children with perceived hypernasal resonance (PHR) after palatoplasty and those with perceived normal resonance (PNR), and to assess the possible influence of language on articulation.

SETTING

Two hospital cleft lip and palate centers in mainland China.

PARTICIPANTS

Thirty-one speakers were allocated into two groups based on perceptual judgment results of their resonance provided by three speech therapists: one group with PNR (n=20, average age=9.3 years), and another group with PHR (n=11, average age=8.3 years). All participants had no known hearing or cognitive deficits.

INTERVENTION

Articulation was evaluated using two Mandarin Chinese assessment tools, the Putonghua Segmental Phonology Test and the Deep Test for Cleft Palate Speakers in Putonghua. Speaker consonant accuracy was evaluated by two experienced speech therapists.

RESULTS

Compared to individuals with PNR, the PHR group exhibited more difficulties on production of unaspirated consonants, including/b/,/t/,/k/,/ts/,/tʂ/ and/tɕ/, than for aspirated consonants.

CONCLUSION

The distinctive feature of aspiration in Mandarin phonology brought a language specific pattern to consonant production among those speakers with PHR after primary palatal closure.

Prevalence and types of articulation errors in Saudi Arabic-speaking children with repaired cleft lip and palate

OBJECTIVES

The purpose of this study was to assess prevalence and types of consonant production errors and phonological processes in Saudi Arabic-speaking children with repaired cleft lip and palate, and to determine the relationship between frequency of errors on one hand and the type of the cleft. Possible relationship between age, gender and frequency of errors was also investigated.

METHODS

Eighty Saudi children with repaired cleft lip and palate aged 6-15 years (mean 6.7 years), underwent speech, language, and hearing evaluation. The diagnosis of articulation deficits was based on the results of an Arabic articulation test. Phonological processes were reported based on the productivity scale of a minimum 20% of occurrence. Diagnosis of nasality was based on a 5-point scale that reflects severity from 0 through 4. All participants underwent intraoral examination, informal language assessment, and hearing evaluation to assess their speech and language abilities. The Chi-Square test for independence was used to analyze the results of consonant production as a function of type of CLP and age.

RESULTS

Out of 80 participants with CLP, 21 participants had normal articulation and resonance, 59 of participants (74%) showed speech abnormalities. Twenty-one of these 59 participants showed only articulation errors; 17 showed only hypernasality; and 21 showed both articulation and resonance deficits. CAs were observed in 20 participant. The productive phonological processes were consonant backing, final consonant deletion, gliding, and stopping. At age 6 and older, 37% of participants had persisting hearing loss.

CONCLUSIONS

Despite early age at time of surgery (mean 6.7 months) for the studied CLP participants in this study, a substantial number of them demonstrated articulation errors and hypernasality. The results showed desirable findings for diverse languages. It is especially interesting to consider the prevalence of glottal stops and pharyngeal fricatives in a population for whom these sound are phonemic.

The impact of palatal repair before and after 6 months of age on speech characteristics

OBJECTIVE

Optimal timing of palatal repair is still subject of discussion. Although literature provides some evidence that palatal closure prior to 6 months positively influence speech outcome in children with clefts, only few studies verified this hypothesis. The purpose of this study was to describe and compare articulation and resonance characteristics following early (≤6 months) and later (>6 months) palatal repair, performed using the Sommerlad technique.

METHODS

Comparison was made between 12 Ugandan children with isolated cleft (lip and) palate following early palatal repair (mean age: 3.3 m) and 12 Belgian patients with later palatal repair (mean age: 11.1 m), matched for cleft type, age and gender. A Ugandan and Belgian age- and gender-matched control group without clefts was included to control for language, culture and other environmental factors. Articulation assessments consisted of consonant inventories and phonetic and phonological analyses that were based on consensus transcriptions. In addition, resonance was evaluated by perceptual consensus ratings and objective mean nasalance values.

RESULTS

The Belgian and Ugandan control groups were comparable for the majority of the variables. Comparison of cleft palate groups revealed no clinically relevant significant group differences for consonant inventory or phonological processes. Phonetic analysis showed significantly more distortions in the Belgian cleft palate group due to higher occurrence frequencies for (inter)dental productions of apico-alveolar consonants. Neither perceptual consensus ratings of hypernasality, hyponasality, cul-de-sac resonance and nasal emission/turbulence, nor objective mean nasalance values for oral speech samples revealed significant group differences (p>0.05).

CONCLUSION

Articulation and resonance characteristics of young children following palatal repair before and after 6 months of age seem to be at least comparable.

Impact of sleep and breathing in infancy on outcomes at three years of age for children with cleft lip and/or palate

STUDY OBJECTIVES

To evaluate the relationship between sleep disordered breathing (SDB) in early infancy and outcomes at 3 years of age in children with cleft lip and/or palate (CL/P).

DESIGN

Observational follow-up study.

SETTING

Multidisciplinary CL/P clinic, tertiary centre.

PARTICIPANTS

Children with CL/P who participated in a study of sleep and breathing in infancy.

MEASUREMENTS AND RESULTS

The families of 52 children were approached for this follow-up study. The children underwent neurocognitive (Bayley Scales of Infant and Toddler Development, Third Edition; BSID-III), quality of life (Infant/Toddler Quality of Life Questionnaire; ITQOL), and growth assessments at 3 years. The families of 33 children (66%) completed follow-up at 36.7 ± 1.4 months. The apnea-hypopnea index (AHI) in infancy was 23.9 ± 18.0 events/h. Mean group BSID-III scores fell within the standardized normal range (10 ± 3) for all domains; however, language scores were lower than control children. Quality of life scores and growth parameter z-scores were similar to published control data. PSG variables in infancy showed significant relationships with outcomes at 3 years of age; lower percentage of AS/REM sleep was associated with lower cognition score; more obstructive events were associated with lower global behavior ITQOL score; and higher number of respiratory events in infancy was associated with lower weight z-score.

CONCLUSION

Neurocognition, quality of life, and growth measures from children with CL/P fall within a normal range; however, scores in the language domain are lower than controls. Sleep and respiratory elements of SDB in infancy appear to modify these outcomes at 3 years of age.

Evaluation of speech errors in Putonghua speakers with cleft palate: a critical review of methodology issues

Speech errors associated with cleft palate are well established for English and several other Indo-European languages. Few articles describing the speech of Putonghua (standard Mandarin Chinese) speakers with cleft palate have been published in English language journals. Although methodological guidelines have been published for the perceptual speech evaluation of individuals with cleft palate, there has been no critical review of methodological issues in studies of Putonghua speakers with cleft palate. A literature search was conducted to identify relevant studies published over the past 30 years in Chinese language journals. Only studies incorporating perceptual analysis of speech were included. Thirty-seven articles which met inclusion criteria were analyzed and coded on a number of methodological variables. Reliability was established by having all variables recoded for all studies. This critical review identified many methodological issues. These design flaws make it difficult to draw reliable conclusions about characteristic speech errors in this group of speakers. Specific recommendations are made to improve the reliability and validity of future studies, as well to facilitate cross-center comparisons.

Nasalance scores for normal Korean-speaking adults and children

There are numerous nasometric studies to date, including normative nasalance scores for various languages as well as nasometric differences in age, gender, race and region except the Korean language. In this regard, we sought to establish normative nasalance scores for Koreans. We created speech samples based on the everyday use of phonemes in the Korean language which were syntactically simple for children. In addition, we analysed nasometric features based on age and gender and confirmed test-retest reliability. The study included 108 children (54 girls and 54 boys, aged 7-11 years) and 108 adults (54 women and 54 men, aged 18-29 years) with normal articulation, resonance, voice and hearing. Nasometer II 6400 was used to measure the nasalance scores. The subjects read or repeated three speech stimuli, each consisting of 33, 36 and 24 syllables: (1) an oral passage devoid of nasal consonants, (2) an oro-nasal passage and (3) nasal sentences. For each stimulus, mean nasalance scores were obtained and gender or age dependence was analysed, using two-way analyses of variance. The mean nasalance scores for the oral passage, oro-nasal passage and nasal sentences were 11.69% (standard deviation (SD) 3.68), 34.04% (SD 4.88) and 63.72% (SD 6.07), respectively. Female speakers exhibited significantly higher nasalance scores than male speakers on the oro-nasal passage (p = 0.000) and nasal sentences (p = 0.004). Children exhibited significantly higher nasalance scores than adults on nasal sentences (p = 0.000). The nasalance scores in children and females were a little higher. Korean normative data will provide reference information in the evaluation and treatment of resonance problems.

Longitudinal comparison of early speech and language milestones in children with cleft palate: a comparison of US and Slovak children

The purpose of this study was to compare early speech and language development of children with and without cleft lip and/or palate (CLP) in the US and Slovakia from 6 to 24 months of age. Thirty-two children from the US (eight with CLP and eight noncleft) and Slovakia (eight with CLP and eight noncleft) participated in this study. The children were videotaped at four time points for 30 minutes during mother-child interaction with play sets controlled for early-developing sounds in each language. Mean Babbling Level, consonant inventories, number of different words and mean length of utterance were calculated for 6- to 24-month samples. Results indicated that the US and Slovak groups showed similar performance across the ages. Cleft and noncleft groups showed significant differences in acquisition of all of the speech and language measures. High-pressure consonants, particularly alveolar place of articulation, were problematic for children with CLP.

A Restricted Test of Single-Word Intelligibility in 3-Year-Old Children with and without Cleft Palate

Objective

In a previous study, children with cleft palate with hard palate closure at 12 months of age showed more typical phonological development than did children with an unrepaired hard palate at 36 months of age. This finding was based on narrow transcription of word initial target consonants obtained from a simple naming test. To evaluate the relevance of this finding, we investigated how well the children's target words were understood by 84 naive listeners.

Design

A cross-sectional study.

Participants

Data obtained from 28 children with unilateral cleft lip and palate, 3 years of age, who received hard palate closure at either 12 months (hard palate repaired; HPR) or 36 months (hard palate unrepaired; HPU) were compared with data obtained from 14 age-matched, typically developing control children.

Methods

Video recordings of the children naming target words were shown to 84 naive listeners between 15 and 24 years of age who typed the word they heard.

Results

The findings of this study indicated that naive listeners correctly identified a larger percentage of words in the control children followed by children in the HPR group. Children in the HPU group were more difficult for the naive listeners to understand. The error of retraction/backing of alveolar target consonants to velar place of articulation occurred frequently and most often in the HPU group and was found to have a negative effect on intelligibility.

Speech Results after One-Stage Palatoplasty with or without Muscle Reconstruction for Isolated Cleft Palate

Objective

To investigate speech outcome between children with isolated cleft palate undergoing palatoplasty with and without muscle reconstruction and to compare speech outcomes between cleft and noncleft children. The number of subsequent velopharyngeal flaps was compared with respect to surgical techniques and cleft extent.

Design

Cross-sectional retrospective study.

Participants

One hundred four children aged 4 years, 0 months to 6 years, 0 months, 33 with isolated cleft of the soft palate, 53 with isolated cleft of the hard and soft palate, and 18 noncleft children.

Interventions

Two primary palate repair techniques: minimal incision technique (MIT) and minimal incision technique including muscle reconstruction (MITmr).

Main Outcome Measures

Perceptual judgment of seven speech parameters assessed on a five-point scale.

Results

No significant differences in speech outcomes were found between MIT and MITmr surgery groups. The number of velopharyngeal flaps was significantly lower after MITmr surgery compared to MIT surgery. The number of flaps was also significantly lower in children with cleft of the soft palate compared to children with cleft of the hard and soft palate. Children with cleft of the soft palate had significantly less glottal articulation and weak pressure consonants compared to children with cleft of the hard and soft palate.

Conclusions

The MITmr surgery technique was not significantly superior to the MIT technique regarding speech outcomes related to velopharyngeal competence, but had fewer velopharyngeal flaps, which is contradictory. Until a larger sample can be studied, we will continue to use MITmr for primary palate repair.

Cleft lip and/or palate and breathing during sleep

Cleft of the lip and/or palate (CL/P) is a common defect which is associated with changes in facial structures and a smaller upper airway. As a result, infants and children with CL/P have an increased risk of sleep disordered breathing (SDB). This paper will review the anatomical and functional factors which place infants and children with CL/P at increased risk of SDB as well as review the literature which defines the magnitude of this risk. The information available on treatment of SDB in infants and children with CL/P will be presented. Finally, outstanding issues relevant to SDB in children with CL/P are discussed with direction for future research.

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.

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.