Universal Parameters for Reporting Speech Outcomes in Individuals with Cleft Palate

Can Hypernasality be Reliably Rated Using the American English Phrase Sample as a Part of the Cleft Audit Protocol for Speech-Augmented-Americleft Modification (CAPS-A-AM) Protocol?

BackgroundThe American English Phrase Sample is an alternative repetition stimulus that can be used as a part of the Cleft Audit Protocol for Speech-Augmented-Americleft Modification.ProblemReliability for rating hypernasality is unknown when the phrase sample is used.SolutionAssessed intra- and interrater reliability for rating hypernasality.What we didIntrarater reliability was k = 0.76-0.91 and interrater reliability was k = 0.63-0.77. The phrase sample had the same reliability for rating hypernasality as the sentence sample.

Laryngeal Aerodynamics, Acoustics, and Hypernasality in Children With Cleft Palate

OBJECTIVE

The objective of this study was to examine the relationship between laryngeal aerodynamics, acoustics, and hypernasality in children with cleft palate with or without lip (CP ± L).

METHOD

This study used a prospectively performed cross-sectional design. Fifty-six children between the ages of 6 and 17 years with CP ± L participated (Mage= 11.7, SD = 3.4; male = 32, female = 24). Children were separated into four groups based on auditory-perceptual ratings of hypernasality made using the Cleft Audit Protocol for Speech-Augmented-Americleft Modification protocol. Laryngeal aerodynamic measures including subglottal pressure, transglottal airflow, laryngeal aerodynamic resistance (LAR), and phonation threshold pressure were collected. Acoustic measures of smoothed cepstral peak prominence (CPP) and low-to-high ratio on sustained vowels and connected speech were also considered. Analyses controlled for age, sex, auditory-perceptual ratings of voice quality, and speech intelligibility.

RESULTS

Children with minimally or mildly hypernasal resonance demonstrated significantly increased subglottal pressure, reduced transglottal airflow, and increased LAR, when compared with children with balanced or moderately hypernasal resonance. CPP on sustained vowel was significantly lower for children with moderate hypernasality when compared with all other groups-suggesting poorer voice quality. Other acoustic measures were in or near normative pediatric range.

CONCLUSIONS

Children with CP ± L and minimal or mildly hypernasal resonance demonstrated aerodynamic voice measures indicative of vocal hyperfunction. These findings suggest that children with CP ± L may compensate for velopharyngeal dysfunction on a laryngeal level, thus increasing the risk of laryngeal pathology. Future study should explore the relationship between laryngeal function and velopharyngeal port closure and consider how voice problems can be prevented or mitigated in children with CP ± L.

Speech Outcomes of Buccal Myomucosal Flap Palatal Lengthening for Treatment of Velopharyngeal Insufficiency: Systematic Literature Review and Meta-Analysis

ObjectiveBuccal myomucosal flaps (BMF) anatomically lengthen the palate in the treatment of velopharyngeal insufficiency (VPI). We systematically reviewed the existing literature on speech outcome of BMF palatal lengthening.DesignThree databases were used to identify studies of interest published in English. Studies that did not use standardized speech assessments were excluded. PRISMA checklist was followed, and the risk of bias in the included studies was assessed.SettingLong-term follow up of patients.PatientsWith history of cleft palate presenting with VPI.InterventionBMF palatal lengthening.Main Outcome MeasureRandom-effects model meta-analyses were performed for hypernasality, intelligibility, and nasal air emission score improvements, which were derived from reported preoperative and postoperative scores, and controlled for variability of scales and timing of postoperative assessment.ResultsFrom the initial 7115 articles, 13 were included in this review. Two of these had a significant patient overlap and a study with a smaller patient population was excluded. All 12 included articles met the National Institutes of Health Quality Assessment Tool criteria. Six retrospective studies evaluated 230 patients and six prospective studies evaluated 181 patients. The most common indications for BMF were large size of the velopharyngeal gap and prior surgery for VPI. Meta-analyses demonstrated effect sizes below zero, confirming the improvement of standardized assessment scores in patients with VPI after BMF palatal lengthening. Egger regressions revealed low risk of publication bias.ConclusionsBMF palatal lengthening provides adequate treatment for VPI in patients with large velopharyngeal gap size and a history of prior unsuccessful surgery.

Intranetwork and Internetwork Functional Connectivity Changes Related to Speech Disorders in Adults With Cleft Lip and Palate

Cleft lip and palate (CLP) may induce alterations in functional connectivity (FC) throughout the whole brain, potentially leading to speech dysfunctions; however, the precise neurobiological mechanisms involved remain unknown. This study aimed to systematically examine the consequences of neurological impairments associated with CLP on whole-brain FC and speech functionality. A total of 33 CLP individuals and 41 control participants were included in this study. Eight meaningful brain networks were identified through independent component analysis (ICA). The intergroup differences and correlations with speech scores for both intranetwork and internetwork FC were calculated. We observed decreased FC within the sensorimotor network (SMN), default mode network (DMN), and cerebellar network (CN) and increased FC within the executive control network (ECN). Additionally, FC was enhanced between the SMN and the auditory network (AN), attention network (ATN), and salience network (SAN); between the DMN and the visual network (VN) and ECN; and between two independent components of the DMN. Furthermore, significant correlations were observed between altered FC and speech assessment scores. Our research demonstrated that brain plasticity in CLP individuals with speech deficits involves widespread changes in brain connectivity, significantly improving our understanding of the neural basis of speech impairment in CLP individuals.

Diagnosis and Treatment of Speech Disorders in Children With a Cleft (Lip and) Palate: A State-Of-The-Art Overview

In children born with a cleft in the palate with or without a cleft in the lip (CP±L), velopharyngeal insufficiency may persist even after successful surgical closure of the palate. This results in speech disorders including both resonance and speech sound disorders. These speech disorders may have a severe impact on the children's speech understandability and speech acceptability which may, in turn, influence psychosocial well-being, quality of life, and inclusion into society. This article provides an overview of the most important speech characteristics per age group (ie, 0-4​​​​​​, 4-6, 6-12, and >12 y). In addition, a state-of-the-art overview of current practices in speech diagnosis and speech intervention is included.

'Suspension Palatoplasty' - A new Method of Primary Palate Repair for Speaking Un-Repaired Clefts

ObjectiveTo design a technique of palate repair with predictable Velo Pharyngeal (VP) closure and normal speech - 'Suspension Palatoplasty' in speaking unrepaired Cleft Palate (CP) patients. To evaluate the results of patients with CP operated using the technique of 'Suspension palatoplasty' from 2014 -2018 in terms of surgical complications and speech outcomes.DesignAn ambi-spective longitudinal clinical study.SettingComprehensive cleft care clinic in a private trust hospital.Patients/ ParticipantsPatients above 6 years of age with isolated CP, cleft lip and palate (CLP), operated using 'Suspension Palatoplasty' technique between 2014 and 2018 were included with minimum follow up period of 5 years. Subjective speech evaluation was done by two speech therapists and analysed.InterventionAuthor designed the technique of 'Suspension Palatoplasty' which aims to suspend the soft palate repaired by 'Hybrid Palatoplasty' technique, close to the nasopharynx using narrow pharyngeal flap with the pedicle based superiorly at adenoids, for an acceptable VP closure.Main Outcome MeasuresSpeech outcome and surgical complications were assessed.ResultsOut of 94 cases operated with age ranging from 6 to 45 years, 59 (62.8%) had normal speech, 12 (12.8%) had articulation errors but with no Velo-Pharyngeal Insufficiency (VPI) and 23 patients (24.4%) had hypernasality/ nasal emission (Suspected VPI). None of them had difficulty in breathing but one patient had snoring.Conclusion'Suspension Palatoplasty' is a simple primary operation with excellent speech outcomes with no obstructive sequelae in patients with speaking unrepaired cleft palate.

Development of a Core Outcome Set for the Audit of Cleft Care in Malaysia

OBJECTIVE

To develop a core outcome set for the audit of cleft care in Malaysia.

DESIGN

To generate a core outcome set for patients dealing with cleft lip and/or palate within Malaysia, a combination of scholarly research reviews and consensus-driven methodologies, such as questionnaires and collaborative discussions, were utilized to guide the development process.

SETTING

Multicenter study. Feedback obtains via face-to-face and online interaction.

PARTICIPANTS

Cleft Clinicians, Cleft Lip and Palate Association of Malaysia members, hospitals, and government bodies personal.

MAIN OUTCOME MEASURE

Participants provide their feedback and suggestions of each outcome measure.

RESULTS

Through a deliberative process, agreement was established on a uniform set of outcome measures selected from an initial list of 108 potential outcomes. These agreed-upon measures were classified into 12 primary domains: demographic, cleft detail, pregnancy, general pediatric, otolaryngology/audiology, speech, surgical, orthodontics, pediatric dentistry, radiology, photographs, and study models.

CONCLUSION

A specialized core outcome set has been successfully developed for patients with cleft lip and/or palate, aiming to facilitate its implementation within the Malaysian healthcare system.

Listening like a speech-training app: Expert and non-expert listeners' goodness ratings of children's speech

Speech training apps are being developed that provide automatic feedback concerning children's production of known target words, as a score on a 1-5 scale. However, this 'goodness' scale is still poorly understood. We investigated listeners' ratings of 'how many stars the app should provide as feedback' on children's utterances, and whether listener agreement is affected by clinical experience and/or access to anchor stimuli. In addition, we explored the association between goodness ratings and clinical measures of speech accuracy; the Percentage of Consonants Correct (PCC) and the Percentage of Phonemes Correct (PPC). Twenty speech-language pathologists and 20 non-expert listeners participated; half of the listeners in each group had access to anchor stimuli. The listeners rated 120 words, collected from children with and without speech sound disorder. Concerning reliability, intra-rater agreement was generally high, whereas inter-rater agreement was moderate. Access to anchor stimuli was associated with higher agreement, but only for non-expert listeners. Concerning the association between goodness ratings and the PCC/PPC, correlations were moderate for both listener groups, under both conditions. The results indicate that the task of rating goodness is difficult, regardless of clinical experience, and that access to anchor stimuli is insufficient for achieving reliable ratings. This raises concerns regarding the 1-5 rating scale as the means of feedback in speech training apps. More specific listener instructions, particularly regarding the intended context for the app, are suggested in collection of human ratings underlying the development of speech training apps. Until then, alternative means of feedback should be preferred.

Classification of speech nasality of individuals with cleft lip and palate with distinct ordinal scales

PURPOSE

To investigate whether there is a difference in the classification of speech hypernasality by inexperienced listeners using different ordinal scales; to verify the agreement of the listeners in the analyses when using these scales; and to verify whether the order in which the scales are presented influences the results.

METHODS

Twenty Speech-Language Pathology students classified the degrees of hypernasality of 40 (oral) samples from patients with cleft lip and palate. Ten performed the classifications using a 4-point scale (absent, mild, moderate, and severe) and, after two weeks, using a 3-point scale (absent, slightly hypernasal, and very hypernasal). Other ten students performed the same classifications, but in reverse order. The classifications were made remotely and documented on a form.

RESULTS

The average percentage of correct responses by the students, in relation to the gold standard, was significantly higher for the 3-point scale. There was no significant interaction between the order of presentation and the scale for the percentage of correct classifications. The students' agreement with the gold standard assessment was fair (3-point scale) and moderate (4-point scale). The mean percentage of agreement of the intra-rater analyses was significantly higher for the 3-point scale. There was no significant interaction between presentation order and scale for the percentage of intra-rater classifications. The Kappa coefficient index showed more favorable intra-rater agreement for the reduced scale.

CONCLUSION

The reduced scale favored the classification of speech hypernasality by listeners and can be considered an important strategy to favor the initial evaluations of students in Speech Therapy during their training.

Immediate individual effects of intensive group speech intervention on speech and health-related quality of life in adolescents with cleft palate: a descriptive study in the Philippines

INTRODUCTION

This descriptive study investigated the immediate individual effects of intensive group speech intervention on speech, health-related quality of life, and satisfaction in adolescents born with a cleft (lip and) palate (CP ± L) in the Philippines.

METHODS

Four Filipino adolescents with a repaired CP ± L (age range = 17 to 23 years) were included. They presented with at least one cleft-related speech sound error. They received 6 h of intensive group speech intervention over 4 consecutive days (i.e. 1 h and 30 min of therapy each day). Pre- and post-intervention outcomes were collected for speech, health-related quality of life, and satisfaction with group intervention. Individual participant data were reported.

RESULTS

The speech of all four participants improved to a clinically relevant degree for the percentage correctly produced consonants (PCC). Speech understandability and acceptability also improved in every participant. PCC scores of two participants were on a level with peers following the group sessions.

DISCUSSION

Speech and health-related quality of life outcomes improved in all four participants after intensive group intervention. However, not everyone reached the level of peers following 6 h of intervention. Participants who presented with a combination of cleft-related speech sound errors might have benefited from a larger intervention dosage.

Adaptive insights: dynamic assessment for speech sound intervention in a child with cleft lip and palate

Dynamic assessment (DA) is a new approach to evaluating speech and language disorders, focusing on the learning process over static abilities. It involves a test-teach-retest format and uses the mediated learning experience (MLE) to measure a child's modifiability through intervention efforts. This method is especially relevant for children with cleft lip and palate (CLP). A study on DA in CLP aims to demonstrate its effectiveness in creating personalised intervention plans. The study involved a child with a history of repaired CLP presenting with misarticulation and hypernasality. Over five 45-min sessions of MLE teletherapy with a speech-language pathologist, the child's modifiability across speech errors was observed. The results showed varying levels of modifiability, emphasising the importance of identifying and using a child's learning potential in speech sound production.

Prenatal to Adulthood: The Responsibility of the Speech-Language Pathologist on the Comprehensive Cleft Palate and Craniofacial Team

PURPOSE

Comprehensive cleft care is an important component when caring for a child with cleft palate with or without cleft lip (CP ± L). Speech-language pathologists (SLPs) serve different capacities on comprehensive cleft palate and craniofacial teams.

METHOD

This tutorial highlights the role of the SLP on the cleft palate and craniofacial team from the prenatal consultation to adulthood. This tutorial emphasizes the importance of collaboration between the cleft team SLP and other professionals on a comprehensive cleft team. Additionally, the tutorial provides education for feeding infants with CP ± L and focuses on assessment and treatment of children with CP ± L before and after the palate repair. Finally, this tutorial underscores the importance of working as part of and collaborating with interdisciplinary team members.

RESULTS

SLPs are an essential member of comprehensive cleft teams in addition to other medical providers. SLPs play a critical role on these multidisciplinary teams and are fundamental to the assessment and treatment of feeding, speech, language, and resonance disorders in children with CP ± L.

CONCLUSION

It is critical that SLPs are involved in comprehensive cleft team care from the prenatal consultation through adulthood to monitor resonance, speech, and language development and outcomes.

Does speech improve after delayed palatal closure in Filipino adults? Effects of combined palatal repair, buccinator flaps and suspension pharyngeal flap

BACKGROUND

Adults presenting with unrepaired cleft palate are not a rare occurrence in middle-income countries. However, many surgeons are hesitant to operate on these individuals because of the challenges in repairing the wide adult cleft palate, as well as concerns regarding any improvement in speech in older patients. Unfortunately, the literature on the effect of delayed palatal closure is scarce.

AIMS

To investigate the effect of delayed palatal closure on speech and self-reported satisfaction in Filipino adults born with a cleft palate.

METHODS & PROCEDURES

A total of 17 adults (mean age = 23.31 years) who underwent delayed palatal closure in the Philippines (a middle-income country) using a three-step surgical procedure (palatal repair, buccinator flaps and suspension pharyngeal flap) were included in this study. Pre- and post-operative speech assessments were conducted. Nasalance values and the absence or presence of velopharyngeal insufficiency (VPI) were determined using the nasometer and videofluoroscopic assessments, respectively. A self-report questionnaire was administered to evaluate satisfaction with the procedure and their speech.

OUTCOMES & RESULTS

Statistically significant improvements in speech understandability and speech acceptability were observed after delayed palatal closure. With regard to resonance and nasal airflow, the presence of hypernasality and nasal emission significantly decreased post-surgery. Videofluoroscopic data showed improved velopharyngeal closure following delayed palatal closure. Participants reported that their speech was significantly more intelligible in different contexts. No differences in articulation were observed before and after surgery.

CONCLUSIONS & IMPLICATIONS

Considering the positive speech outcomes in terms of speech understandability, speech acceptability, hypernasality, nasal emission, velopharyngeal closure and self-reported satisfaction, it is worthwhile to operate on adults with unrepaired palatal clefts. Post-operative speech therapy to improve articulation remains necessary.

WHAT THIS PAPER ADDS

What is already known on the subject Adults presenting with unrepaired cleft palate are not a rare occurrence in middle-income countries. However, many surgeons are hesitant to operate on these individuals because of challenges in repairing the wide adult cleft palate as well as concerns regarding any improvement in speech in older patients. What this paper adds to the existing knowledge This study investigated the effect of delayed palatal closure on speech and self-reported satisfaction in Filipino adults born with a cleft palate. We described the use of a unique three-step surgical procedure including palatal repair, buccinator flaps and suspension pharyngeal flap. Significant improvements in speech understandability and speech acceptability were observed after delayed palatal closure using this three-step surgical sequence. The presence of hypernasality and nasal emission significantly decreased post-surgery and improved velopharyngeal functioning was observed. What are the potential or clinical implications of this work? It is worthwhile to operate on adults with unrepaired palatal clefts considering the positive speech outcomes in terms of speech understandability, speech acceptability, hypernasality, nasal emission, velopharyngeal functioning and self-reported satisfaction. Post-operative speech therapy to improve articulation remains necessary.

How differences in anatomy and physiology and other aetiology affect the way we label and describe speech in individuals with cleft lip and palate

BACKGROUND

Speech in individuals with cleft lip and/or palate (CLP) is a complex myriad of presenting symptoms. It is uniquely associated with the structural difference of velopharyngeal insufficiency (VPI), together with a wide and heterogeneous range of other aetiologies which often co-occur. The nature of the speech sound disorder (SSD) including VPI may also change over the course of an individual's care pathway. Differences in terminology and approaches to analysis are currently used, resulting in confusion internationally. Additionally, current diagnostic labels and classification systems in SSD do not capture the complexity and full nature of speech characteristics in CLP.

AIMS

This paper aims to explore the different aetiologies of cleft palate/VPI speech and to relate aetiology with speech characteristic(s). In so doing, it attempts to unravel the different terminology used in the field, describing commonalities and differences, and identifying overlaps with the speech summary patterns used in the United Kingdom and elsewhere. The paper also aims to explore the applicability of current diagnostic labels and classification systems in the non-cleft SSD literature and illustrate certain implications for speech intervention in CLP.

METHODS AND PROCEDURES

The different aetiologies were identified from the literature and mapped onto cleft palate/VPI speech characteristics. Different terminology and approaches to analysis are defined and overlaps described. The applicability of current classification systems in SSD is discussed including additional diagnostic labels proposed in the field.

OUTCOMES AND RESULTS

Aetiologies of cleft palate/VPI speech identified include developmental (cognitive-linguistic), middle ear disease and fluctuating hearing loss, altered oral structure, abnormal facial growth, VPI-structural (abnormal palate muscle) and VPI-iatrogenic (maxillary advancement surgery). There are four main terminologies used to describe cleft palate/VPI speech: active/passive and compensatory/obligatory, which overlap with the four categories used in the UK speech summary patterns: anterior oral cleft speech characteristics (CSCs), posterior oral CSCs, non-oral CSCs and passive CSCs, although not directly comparable. Current classification systems in non-cleft SSD do not sufficiently capture the full nature and complexity of cleft palate/VPI speech.

CONCLUSIONS AND IMPLICATIONS

Our attempt at identifying the heterogeneous range of aetiologies provides clinicians with a better understanding of cleft palate/VPI speech to inform the management pathway and the nature and type of speech intervention required. We hope that the unravelling of the different terminology in relation to the UK speech summary patterns, and those used elsewhere, reduces confusion and provides more clarity for clinicians in the field. Diagnostic labels and classification require international agreement.

WHAT THIS PAPER ADDS

What is already known on the subject Speech associated with cleft palate/velopharyngeal insufficiency (VPI) is a complex myriad of speech characteristics with a wide and heterogeneous range of aetiologies. Different terminology and speech summary patterns are used to describe the speech characteristics. The traditional classification of cleft palate/VPI speech is Articulation Disorder, although evidence is building for Phonological Disorder and contrastive approaches in cleft speech intervention. What this paper adds to existing knowledge This paper explores the range of aetiologies of cleft palate/VPI speech (e.g., altered oral structure, abnormal facial growth, abnormal palate muscle and iatrogenic aetiologies) and attempts to relate aetiology with speech characteristic(s). An attempt is made at unravelling the different terminology used in relation to a well-known and validated approach to analysis, used in the United Kingdom and elsewhere. Complexities of current diagnostic labels and classifications in Speech Sound Disorder to describe cleft palate/VPI speech are discussed. What are the potential or actual clinical implications of this work? There needs to be a common language for describing and summarising cleft palate/VPI speech. Speech summary patterns based on narrow phonetic transcription and correct identification of aetiology are essential for the accurate classification of the speech disorder and identification of speech intervention approaches. There is an urgent need for research to identify the most appropriate type of contrastive (phonological) approach in cleft lip and/or palate.

Cross-Linguistic Nasalance Comparisons: A Review of Speech Sample Sets and Preliminary Consideration of Effect of Lexical Tone

INTRODUCTION

Nasalance is an acoustic representation of perceived nasality with proven clinical and research utility. Its validity is contingent on appropriate speech sample sets and distinct normative databases based on known impact factors such as language and phonetic environment, but little is known about the potential effects of lexical tone on nasalance. Its use in international cross-linguistic studies necessitates definition and added considerations of speech sampling protocol.

METHODS

Part I: a methodological review was undertaken using PRISMA (2020), the Scottish Intercollegiate Guidelines Network (SIGN) Methodology Checklist for evaluating the risk of bias, and calculation of effect sizes and/or visual displays using tables showing the grouping of similar data for the synthesis of findings. Part II: a pilot study explored the effect of lexical tone on nasalance in Cantonese, a lexical tone language.

RESULTS

Part I: a total of 17 studies met the inclusion criteria. In addressing possible confounders and minimizing the risk of bias, 13 studies were assigned an overall quality rating of acceptable (+) and the remaining 4, a high rating (++). For the 9-word string, there was a (non-clinical) difference of 3-5% between Swedish and Brazilian-Portuguese, and a moderate effect size for age (d = 0.49); for the consonant-vowel syllables set, clinical differences across languages were identified for adults and between 5 and 10% for children and adolescents. Part II: the pilot study showed a significant effect of lexical tone on nasalance, where nasalance for the high-level tone 1 was significantly higher than that for high-rising tone 2, low-rising tone 5, and low-falling tone 4.

DISCUSSION

There is a need for further evidence from other languages, including tonal languages, to better define the evidence and speech methodology of international cross-linguistic nasalance studies.

Demystifying Velopharyngeal Dysfunction for Plastic Surgery Trainees Part 2: Speech Fundamentals and Perceptual Speech Assessment

Velopharyngeal dysfunction (VPD) is the inability to achieve proper closure of the velopharyngeal (VP) port, affecting speech and swallowing. The gold standard for diagnosis is auditory-perceptual speech evaluation by a specialized speech-language pathologist. This 3-part series provides a comprehensive discussion on (1) the anatomy and physiology of the velopharyngeal mechanism, (2) fundamental speech terminology and principles of perceptual speech assessment for VPD, and (3) techniques for objective evaluation of the VP port and surgical decision-making process. In part 2, the authros begin with the concepts and terminology required to understand the perceptual speech assessment of VPD, including resonance, articulation, and the differentiation between consonants and vowels. We review the types of speech samples used for evaluation such as single-word articulation tests, syllable repetition, sentence repetition, and spontaneous connected speech. Finally, we discuss the auditory-perceptual speech assessment for VPD, including the assessment of resonance, nasal air emission, articulation, and voice quality. The use of rating scales like the Pittsburgh Weighted Speech Scale (PWSS) and the Cleft Audit Protocol for Speech-Augmented-Americleft Modification (CAPS-A-AM) is highlighted. In addition, the significance of intraoral examinations, visual-tactile-auditory evaluations, and the assessment of voice quality are covered. Most textbook chapters discussing this topic assume a foundational knowledge of speech-language pathology, which a surgical trainee may lack. This study aimed to bridge the gap between surgical training and speech pathology, providing a comprehensive resource to enhance the understanding and management of VPD.

Velopharyngeal Gap Size During Sustained Vowel Production Correlates With Perceptual Ratings of Hypernasality in Connected Speech

PURPOSE

The purpose of this study was to investigate the relationship between perceptual ratings of hypernasality made during connected speech and velopharyngeal (VP) gap size measured in millimeters in the sagittal plane during sustained vowel production using magnetic resonance imaging (MRI).

METHOD

A retrospective cross-sectional analysis was completed. A subgroup of 110 participants from another study with an Mage of 10.1 years presenting for management of VP insufficiency was included. Perceptual ratings of hypernasality during connected speech and measurement of gap size during sustained /i/ production on MRI were performed by raters blinded to the participants' medical and surgical history.

RESULTS

There was a moderate-to-strong, positive correlation (r = .61; p < .001) between hypernasality ratings and VP gap size measured on MRI using sustained /i/. The odds of a higher hypernasality rating increased as the gap size increased (odds ratio = 1.34; 95% CI [1.20, 1.49]; p < .001). The predicted probability for hypernasality ratings of none/minimal/mild steadily decreased as the gap size increased indicating that lower ratings of hypernasality were associated with smaller gap sizes. For the rating of "moderate" hypernasality, the predicted probability of the rating steadily increased up to 8 mm and then decreased as the gap size continued to increase. The predicted probability for a hypernasality rating of "severe" consistently increased as the gap size increased.

CONCLUSIONS

Hypernasality ratings made at the connected speech level were significantly associated with VP gap size as measured during sustained vowel production. These findings suggest sustained vowel production elicited on MRI may adequately characterize VP gap size in the evaluation of VP insufficiency.

Effects of Suspension Pharyngeal Flap on Speech in Filipino Individuals with Velopharyngeal Insufficiency

INTRODUCTION

This study investigated the effects of suspension pharyngeal flap surgery for velopharyngeal insufficiency (VPI) due to cleft palate.

METHODS

Ten Filipino individuals (mean age = 20.63 years, range = 8.4-34.9 years) with a cleft palate who underwent suspension pharyngeal flap surgery for VPI were included in this study. Perceptual and instrumental speech assessments were conducted at two different time points: before surgery (data point 1) and after surgery (data point 2, range = 4-26 weeks postoperatively). Speech intelligibility in different contexts and satisfaction with speech were assessed by the participants themselves using a self-report questionnaire. Additionally, the risk for obstructive sleep apnea was assessed using the Berlin Questionnaire.

RESULTS

Velopharyngeal gap size significantly decreased after the surgery. Additionally, significant improvements in speech understandability and acceptability were observed following the suspension pharyngeal flap procedure. Besides, a significant reduction in hypernasality, nasal emission, and the occurrence of passive articulation errors was seen. No difference in the occurrence of active articulation errors was observed when comparing data pre- and post-surgery. The ten individuals reported to be significantly more intelligible in different contexts after surgery.

CONCLUSION

Improved speech was observed in individuals who received the suspension pharyngeal flap procedure. This procedure also positively influences an individual's intelligibility in different contexts in daily life. In individuals with persisting active articulation errors, post-surgery speech therapy will still be necessary.

Clinical application of usage-based phonology: Treatment of cleft palate speech using usage-based electropalotography

PURPOSE

To investigate whether a novel electropalatography (EPG) therapy, underpinned by usage-based phonology theory, can improve the accuracy of target speech sounds for school-aged children and adults with persistent speech sound disorder (SSD) secondary to cleft palate +/- lip.

METHOD

Six consecutively treated participants (7-27 years) with long-standing speech disorders associated with cleft palate enrolled in a multiple baseline (ABA) within-participant case series. The usage-based EPG therapy technique involved high-volume production of words. Speech was assessed on three baselines prior to therapy, during weekly therapy, at completion of therapy, and 3 months post-therapy. Percent correct of target phonemes in untreated words and continuously connected speech were assessed through acoustic phonetic transcription. Intra- and inter-transcriber agreement was determined.

RESULT

Large to medium treatment effect sizes were shown for all participants following therapy (15-33 sessions). Percentage of targets correct for untreated words improved from near 0% pre-therapy, to near 100% for most target sounds post-therapy. Generalisation of target sounds to spontaneous connected speech occurred for all participants and ranged from 78.95-100% (M = 90.66; SD = 10.14) 3 months post-therapy.

CONCLUSION

Clinically significant speech change occurred for all participants following therapy. Response to the novel therapeutic technique is encouraging and further research is indicated.

Relationship Between Auditory-Perceptual and Objective Measures of Resonance in Children with Cleft Palate: Effects of Intelligibility and Dysphonia

OBJECTIVE

To investigate the relationship between auditory-perceptual ratings of resonance and nasometry scores in children with cleft palate. Factors which may impact this relationship were examined including articulation, intelligibility, dysphonia, sex, and cleft-related diagnosis.

DESIGN

Retrospective, observational cohort study.

SETTING

Outpatient pediatric cranio-facial anomalies clinic.

PATIENTS

Four hundred patients <18 years of age identified with CP ± L, seen for auditory-perceptual and nasometry evaluations of hypernasality as well as assessments of articulation and voice.

MAIN OUTCOME MEASURE

Relationship between auditory-perceptual ratings of resonance and nasometry scores.

RESULTS

Pearson's correlations indicated that auditory-perceptual resonance ratings and nasometry scores were significantly correlated across oral-sound stimuli on the picture-cued portion of the MacKay-Kummer SNAP-R Test (r values .69 to.72) and the zoo reading passage (r = .72). Linear regression indicated that intelligibility (p ≤ .001) and dysphonia (p = .009) significantly impacted the relationship between perceptual and objective assessments of resonance on the Zoo passage. Moderation analyses indicated that the relationship between auditory-perceptual and nasometry values weakened as severity of speech intelligibility increased (P < .001) and when children presented with moderate dysphonia (p ≤ .001). No significant impact of articulation testing or sex were observed.

CONCLUSIONS

Speech intelligibility and dysphonia alter the relationship between auditory-perceptual and nasometry assessments of hypernasality in children with cleft palate. SLPs should be aware of potential sources of auditory-perceptual bias and shortcomings of the Nasometer when following patients with limited intelligibility or moderate dysphonia. Future study may identify the mechanisms by which intelligibility and dysphonia affect auditory-perceptual and nasometry evaluations.

Evaluation of postoperative outcomes in palatoplasty with three soft palate cleft repairs

The aim of this study was to compare the postoperative clinical and functional outcomes of palatoplasty with three soft palate cleft repairs and analyse the factors potentially impacting these outcomes. A retrospective analysis was conducted on a consecutive series of 337 patients who underwent primary cleft palate repair by palatoplasty modified with either Furlow Z-plasty (P-FZP, n = 77), intravelar veloplasty (P-IVV, n = 110), or combined intravelar veloplasty-Furlow Z-plasty (P-IVV-FZP, n = 150). The postoperative outcomes evaluated included wound healing (complete closure/fistula) and velopharyngeal function. Demographic and surgical data were analysed using both univariate and multivariate analysis. There was no significant difference between the groups with regard to the sex distribution, age at repair, cleft width, cleft type, or follow-up duration. However, relaxing incisions were significantly more common with P-FZP (26.0%) and P-IVV (29.1%) compared to P-IVV-FZP (10%) (P = 0.002 and <0.001, respectively). The complete wound closure rate was significantly higher with P-IVV-FZP (97.3%) compared to P-FZP (88.3%) (P = 0.012) and P-IVV (90%) (P = 0.015). The normal velopharyngeal function rate was comparable for P-IVV-FZP (86.7%) and P-FZP (83.1%), and both rates were significantly better than the rate with P-IVV (73.6%) (P = 0.039 and 0.029, respectively). The cleft type and width were identified as factors influencing postoperative outcomes. In conclusion, it may be appropriate to prioritize the palatoplasty with combined intravelar veloplasty-Furlow Z-plasty whenever feasible.

An Evaluation of Autologous Fat Injection as a Treatment for Velopharyngeal Insufficiency: A Review and Integrated Data Analysis

BACKGROUND

Velopharyngeal insufficiency (VPI) is a condition characterized by incomplete separation of the oral and nasal cavities during speech production, thereby leading to speech abnormalities and audible nasal emissions. Subsequently, this adversely impacts communication and potentially interpersonal social interactions. Autologous fat grafting (AFG) to the velopharynx, a minimally invasive technique, aims to improve oronasal separation by providing bulk and advancing the posterior pharyngeal wall toward the soft palate. Despite its potential, the relative novelty of AFG in treating VPI has resulted in reporting of inconsistent indications, varied surgical techniques, and mixed outcomes across existing literature.

METHODS

This systemic review examined the evidence of AFG for VPI treatment over the past decade (2013-2023). A thorough search across five electronic databases yielded 233 studies, with 20 meeting the inclusion criteria (e.g., utilized fat injection as their selected VPI treatment, conducted study in human subjects, did not perform additional surgical procedure at time of fat injection). Selected studies encompassed patient and surgical intervention characteristics, perceptual speech assessment (PSA) scores, gap sizes, nasalance measurements, and complications.

RESULTS

The majority of patients had a prior cleft palate diagnosis (78.2%), in which nasoendoscopy was the prevalent method for visualizing the velopharyngeal port defect. Fat harvesting predominantly occurred from the abdomen (64.3%), with an average injection volume of 6.3 mL across studies. PSA and subjective gap size scores were consistently higher preoperatively than postoperatively. PSA score analysis from seven studies revealed significant and sustained improvements postoperatively. Gap size score analysis from four studies demonstrated similar preoperative and postoperative differences. Complications were reported in 17 studies, yielding a 2.7% summative complication rate among 594 cases.

CONCLUSIONS

Autologous fat grafting has emerged as a minimally invasive, safe, and effective treatment for mild to moderate VPI. However, challenges remain because of variability in patient selection criteria, diagnostic modalities, and outcome measurements. This review underscores the need for randomized control trials to directly compare AFG with standard-of-care surgical interventions, providing more conclusive evidence of its clinical efficacy.

Speech and Resonance Disorders in Children With Cleft Palate: Diagnostic Evaluation and Current Speech Therapy Modalities

This article will provide an overview of how speech and resonance can be impacted in children with cleft palate. The authors will outline evidence-based assessment and treatment approaches commonly used for children with cleft palate and provide information on current initiatives to provide speech therapy. The methods discussed will be the use of telehealth to provide access to speech therapy for patients in areas without speech-language pathologists and the use of speech therapy camps to offer intensive, limited-duration speech therapy for groups of children due to the lack of trained providers in certain geographical regions.

Does Primary Cleft Palate Repair by Furlow Z-Plasty Technique With a Buccinator Myomucosal Flap Change Speech and Middle Ear Outcomes?

BACKGROUND

Children with repaired cleft lip and palate may present with middle ear effusion and disturbed speech due to velopharyngeal (VP) insufficiency. Furlow Z-palatoplasty with a buccinator myomucosal flap is one of the effective surgical techniques for primary cleft palate repair and lengthening of the palate.

PURPOSE OF THE STUDY

This study aimed to evaluate the effect of Furlow Z-palatoplasty with buccal myomucosal flap as a primary cleft palate repair technique on the VP function during speech and the Eustachian tube function.

MATERIALS AND METHODS

Forty patients with non-syndromic cleft lip and palate aged 3 to 7 years surgically repaired with Furlow palatoplasty with a buccinator myomucosal flap were assessed. Perceptual speech assessment, nasopharyngoscopic examination, otoscopic examination, and tympanometry were done for all patients to assess the speech and middle ear function.

RESULTS

The percentage of mild hypernasality was significant in 22.5% of children with repaired cleft lip and palate, while 77.5% showed no hypernasality. Speech intelligibility was normal in 77.5% and mildly affected in 22.5% of children with repaired cleft palate. Compensatory misarticulations were recorded in 12.5% of children. Nasopharyngoscopic examination revealed adequate VP closure in 75% of children with repaired cleft palate. Twenty-five percent of children with repaired cleft lip and palate had middle ear effusion and required myringotomy with insertion of tympanostomy tubes.

CONCLUSION

Primary cleft palate repair with Furlow Z-palatoplasty with buccal myomucosal flap had beneficial effects on speech outcomes. It was associated with a low prevalence of middle ear effusion, and a low number of tympanostomy tubes were needed.

Comparison of intelligibility measures for children with velopharyngeal insufficiency: visual analog scale ratings, interval scales, and orthographic transcription (OT)-based measures

Regardless of the underlying cause for speech impairment in speakers with cleft palate, a universal consequence of cleft palate is reduced speech intelligibility. Still, there is no standardised approach for measuring intelligibility for speakers with cleft speech. The current study aimed to determine the relationship between orthographic transcription (OT)-based measures, interval-scale ratings, and visual analog scale (VAS) ratings for perceptual judgements of intelligibility in speakers with cleft palate as judged by speech-language pathologists (SLPs). The speaker participants were six speakers with velopharyngeal insufficiency secondary to cleft palate. Four sets of sentences from the Hearing in Noise Test were recorded from each speaker. A total of 14 SLPs provided their intelligibility judgement on these speaker's recordings by word-by-word orthographic transcriptions, a visual analog scale (0-100), and a 5-point interval rating scale. A Spearman rank correlation test indicated a negative, strong correlation between OT-based measurements and VAS scores (r = -.94; p = 0.01) and between OT-based measurements and interval rating scores (r = -.77, p = 0.01). A strong, positive correlation was found between scores obtained from VAS and interval rating scales (r = .83, p = 0.05). The strong relationship between the objective measure of intelligibility (i.e. OT-based measure) and a subjective measure of intelligibility (i.e. VAS and interval scale) supports using a less time-consuming VAS as a substitute for orthographic transcription in measuring intelligibility in cleft palate speech.

Effect of Acellular Dermal Matrix on Long-Term Speech Outcomes in Primary Palatoplasty with Radical Intravelar Veloplasty

OBJECTIVE

This study investigates whether the use of acellular dermal matrix (ADM) affects the long-term speech outcomes in patients undergoing primary palatoplasty with radical intravelar veloplasty.

DESIGN

Retrospective cohort study.

SETTING

Tertiary university-affiliated hospital.

PARTICIPANTS

A consecutive cohort of 112 patients who underwent primary palatoplasty with radical intravelar veloplasty from August 2014 to March 2018 were included.

MAIN OUTCOME MEASURES

A 2 × 2 cm-sized ADM was incorporated as an interpositional graft between the oral and nasal lining at the soft-hard palate junction. The perceptual analysis of hypernasality and articulation was performed when the age of the patient reached at least 36 months. Cleft-related characteristics and surgical factors affecting the speech outcomes were investigated.

RESULTS

The ADM was applied in 57 patients with a mean follow-up of45.76 months (SD, 10.69), while no ADM was used in 55 patients with a mean follow-up of 48.43 months (SD, 14.98). Regarding the hypernasality outcome, 33.3% (19 of 57 patients) of the ADM group and 27.3% (15 of 55 patients) of the control group showed a greater than mild-to-moderate degree. The distribution of hypernasality and articulation grade showed no significant difference between the two groups. After controlling for potential risk factors that may affect the speech outcomes, the use of ADM showed no significant relationship with velopharyngeal insufficiency.

CONCLUSION

The use of ADM use in primary palatoplasty with radical intravelar veloplasty is not associated with the alteration of speech function in early childhood.

Models for Predicting Velopharyngeal Competence Based on Speech and Resonance Errors and Velopharyngeal Area Estimation

OBJECTIVE

To develop tools for predicting velopharyngeal competence (VPC) based on auditory-perceptual assessment and its correlation with objective measures of velopharyngeal orifice area.

DESIGN

Methodological study.

PARTICIPANTS AND METHODS

Sixty-two patients with repaired cleft palate, aged 6 to 45 years, underwent aerodynamic evaluation by means of the pressure-flow technique and audiovisual recording of speech samples. Three experienced speech-language pathologists analysed the speech samples by rating the following resonance, visual, and speech variables: hypernasality, audible nasal air emission, nasal turbulence, weak pressure consonants, facial grimacing, active nonoral errors, and overall velopharyngeal competence. The correlation between the perceptual speech variables and velopharyngeal orifice area estimates was analysed with Spearman's correlation coefficient. Two statistical models (discriminant and exploratory) were used to predict VPC based on the orifice area estimates. Sensitivity and specificity analyses were performed to verify the clinical applicability of the models.

RESULTS

There was a strong correlation between VPC (based on the orifice area estimates) and each speech variable. Both models showed 88.7% accuracy in predicting VPC. The sensitivity and specificity for the discriminant model were 92.3% and 97.2%, respectively, and 96.2% and 94.4% for the exploratory model.

CONCLUSION

Two predictor models based on ratings of resonance, visual, and speech variables and a simple calculation of a composite variable, SOMA (Eng. "sum"), were developed and found to be efficient in predicting VPC defined by orifice estimates categories based on aerodynamic measurements. Both tools may contribute to the diagnosis of velopharyngeal dysfunction in clinical practice.

Repeat Buccal Flaps Successfully Reduce Hypernasality in a Patient with Cleft Palate

Surgical intervention can contribute to the development of velopharyngeal insufficiency (VPI) leading to hypernasality and regurgitation. In this case, a patient with a history of bilateral buccal flaps used for her primary CP repair presented to clinic with hypernasality and VPI as assessed by speech exam and imaging. She underwent repeat bilateral buccal flap palatal lengthening with division of the pedicles 3 months later. Three months after her division, her hypernasality score improved from moderate to mild and her posterior gap decreased. This study concluded buccal flaps can be used a second time for patients needing palatal revisions for VPI.

Patients Requiring Multiple Surgeries for Velopharyngeal Insufficiency: Findings From a 10-Year Retrospective Review

This study analyzed patients undergoing multiple surgeries for velopharyngeal insufficiency (VPI) and reviewed their preoperative evaluations and techniques selected for subsequent surgeries. A retrospective chart review was performed including patients having undergone multiple surgeries for VPI at the authors' institution between 2012 and 2022. All patients were evaluated and managed at the author's institution under the direction of 4 senior surgeons. The objective of this study was to provide insight into preoperative evaluation, surgical technique selection, and other factors that may contribute to patients who require multiple VPI surgeries. Of 71 patients having undergone surgery for VPI, 8 required at least 1 additional operation for persistent VPI following the initial intervention. Six patients who initially underwent a superiorly based posterior pharyngeal flap (PPF) required additional surgery, and for those patients' subsequent operations, 5 different techniques were used throughout their treatment. Of the remaining 2 patients who had multiple VPI surgeries, 1 initially received autologous fat transfer and 1 initially underwent a furlow palatoplasty. Finally, 0 patients that initially underwent buccal flaps or collagen injection required further unplanned surgical intervention. This study demonstrates the importance of selecting an appropriate surgical approach when operating on patients following a failed VPI surgery. The algorithm developed from these findings emphasizes the importance of properly identifying the anatomical deficiency resulting from the failed intervention. A review of the advantages of nasopharyngoscopy as a preoperative evaluative technique of velopharyngeal form and function when compared to lateral barium video fluoroscopy was also included.

What Technique Results in the Lowest Rate of Velopharyngeal Insufficiency in Patients With Submucous Cleft Palate? A Systematic Review and Meta-Analysis

Objective: To determine which surgical technique offers the lowest rate of velopharyngeal insufficiency (VPI) without the need for further operative intervention, in pediatric patients with nonsyndromic submucous cleft palate (SMCP). Methods: This systematic review and meta-analysis included articles reporting on nonsyndromic pediatric patients treated surgically during childhood for SMCP, with data on postoperative speech outcomes and/or recommendations for secondary surgery. Main outcome measures included rates of unfavorable speech outcomes defined as persistent VPI requiring secondary surgery and speech outcome data. Results: 15 articles met our inclusion criteria, reporting on 383 children who underwent surgical treatment; 343 patients were included in studies reporting recommendations for secondary surgery. There was 1 randomized comparative trial, 4 comparative studies, and 10 single cohort studies. Eight articles used validated speech assessment tools. Our model showed the proportion of patients recommended for secondary surgery varied between techniques, ranging from 0.0% (CI 0.0, 1000) in pharyngeal flap to 17.8% (CI 8.9, 32.5) in straight line repair techniques, but there was no statistically significant difference between treatments (P = .33). Speech improvement ranged from 44.4% to 100%, with 9 studies recommending secondary surgery for some of their patient series. Conclusions: Although not of statistical significance, pharyngeal flap yields the lowest rate of reoperation as a primary technique for pediatric patients with nonsyndromic SMCP. Delayed repair age inherent to SMCP may render operations that rely on a functional levator muscle with less favorable outcomes. The absence of standardized surgical techniques, speech outcomes, speech therapy, and assessment make comparative analysis and recommendation difficult. We advocate for standardized speech assessment tools to improve future quantitative assessment of cleft surgery outcomes and a randomized controlled trial to better elucidate the preferred first-line technique.

Speech Task Force and Quality of Life after Surgery in Children with Cleft Lip and Palate: Limitation of Professionals

Background  Shortage of speech and language therapists results in lack of speech services. The aims of this study were to find the effectiveness of a combination speech therapy model at Level IV: General speech and language pathologist (GSLP) and Level V: Specific speech and language pathologist (SSLP) in reduction of the number of articulation errors and promotion the quality of life (QoL) for children with cleft palate with or without cleft lip (CP ± L). Methods  Fifteen children with CP ± L, aged 4 years 1 month to 10 years 9 months (median = 76 months; minimum:maximum = 49:129 months) were enrolled in this study. Pre- and post-assessment included oral peripheral examination; articulation tests via Articulation Screening Test, Thai Universal Parameters of Speech Outcomes for People with Cleft Palate, Hearing Evaluation, The World Health Organization Quality of Life Brief_Thai (WHOQOL-BRIEF-THAI) version questionnaire for QoL were performed. Speech therapy included a 3-day intensive speech camp by SSLP, five 30-minute speech therapy sessions by a GSLP, and five 1-day follow-up speech camps by SSLP that provided four 45-minute speech therapy sessions for each child. Results  Post-articulation revealed statistically significant reduction of the numbers of articulation errors at word, sentence, and screening levels (median difference [MD] = 3, 95% confidence interval [CI] = 2-5; MD = 6, 95% CI = 4.5-8; MD = 2.25, 95% CI = 1.5-3, respectively) and improvement of QoL. Conclusion  A speech task force consisting of a combination of Level IV: GSLP and Level V: SSLP could significantly reduce the number of articulation errors and promote QoL.

Effectiveness of secondary furlow palatoplasty with buccal myomucosal flap in correction of velopharyngeal insufficiency in patients with cleft palate

OBJECTIVES

The main purpose of this study was evaluation of the effectiveness of secondary furlow palatoplasty with buccal myomucosal flap (FPBF) for the treatment of velopharyngeal insufficiency (VPI) in patients with a cleft palate who were treated with two flap palatoplasty (TFP) in their primary palate repair.

MATERIAL AND METHODS

Twenty-three medically free children aged 4-8 years with non-syndromic and previously repaired cleft palate via TFP participated in the study. All patients received secondary surgery following the technique of FPBF. Preoperative speech evaluation was done before the secondary repair and 3 months after the surgery using a hypernasal speech scale, speech intelligibility scale, and nasopharyngoscopy.

RESULTS

A statistically significant improvement was observed regarding the degree of hypernasality and speech intelligibility while comparing the preoperative scores after the primary surgery to the postoperative scores after the secondary surgery. In addition, a statistically significant improvement was found in the nasopharyngoscopic assessment.

CONCLUSIONS

The incorporation of a buccal myomucosal flap with Furlow palatoplasty was successful in improving hypernasality, speech intelligibility, and nasopharyngoscopic scores in patients with cleft palate.

TRIAL REGISTRATION

clinicaltrials.gov (NCT05626933).

CLINICAL RELEVANCE

This technique might be the surgical technique of choice while treating patients who are suffering from VPI after cleft palate repair.

Analysis of Risk Factors for Velopharyngeal Insufficiency and Palatal Fistula After Sommerlad-Furlow Palatoplasty

This study aimed to introduce a surgery technique-Sommerlad-Furlow palatoplasty (SFP) and analyze the risk factors of velopharyngeal insufficiency (VPI) and palatal fistula after SFP. Cases after SFP under the age of 5 between 2011 and 2021 were reviewed, and the cases with complete follow-up information were included. Univariate and multivariate logistic regression were used to evaluate the effects of surgical age, surgery technique, surgeon's experience, and cleft type on velopharyngeal function and the occurrence of palatal fistula. SFP is a safe and effective procedure to increase the palatal length and reconstruct the levator veli palatini sling. The speech outcome after SFP was associated with cleft type and age at operation. Age = 1.285 years is the best cutoff value. The fistula occurrence was associated with cleft type only.

Proposed clinical model for predicting speech outcomes in patients undergoing Furlow palatoplasty for velopharyngeal insufficiency after primary palatoplasty

This study aimed to validate the predictors of speech outcomes following Furlow palatoplasty in patients with velopharyngeal insufficiency (VPI) after primary palatoplasty and to propose and validate a model to predict the risk of persistent VPI. The study included patients with VPI after primary palatoplasty who underwent Furlow palatoplasty as a secondary surgery. Eleven variables were included: velar length, pharyngeal cavity depth, velopharyngeal gap, velopharyngeal closure pattern, sex, presence of cleft lip, existence of palatal fistula, surgeon, age at primary palatoplasty, age at secondary surgery, and time interval between primary palatoplasty and secondary surgery. Postoperative speech outcomes were assessed at least 1 year after the secondary surgery and classified as velopharyngeal competence (VPC) or VPI. Variables were analyzed using multivariate logistic regression analysis, and the area under the curve (AUC) was used to validate model accuracy. The study sample comprised 101 patients. Of the patients, 62 had VPC and 39 had VPI after secondary surgery. The results showed a younger age at secondary surgery, a smaller velopharyngeal gap, being female, having a coronal velopharyngeal closure pattern and a velopharyngeal closure ratio of 90% or greater produced a greater probability of VPC. Given the constraints of this study, it appears that the Furlow palatoplasty should be prioritized when the clinical model predicts a substantial likelihood of VPC post-surgery.

Management of Velopharyngeal Dysfunction (VPD) Following Cleft Palate Repair: A Comprehensive Decision-Making Process Based on Severity and Structural Deficiencies

OBJECTIVE

To describe a comprehensive decision-making process for surgical correction of structural Velopharyngeal Dysfunction (VPD) following cleft palate repair and evaluate its efficacy.

DESIGN

Retrospective study.

SETTING

Tertiary care hospital.

PATIENTS

300 consecutive patients with unilateral or bilateral cleft lip and palate (CLP) or isolated cleft palate (CP) diagnosed with clinical VPD following cleft palate repair between 2009 and 2014. Of these 206 patients had structural VPD and underwent surgical correction.

INTERVENTIONS

Surgical corrections were carried out according to the comprehensive two stage decision making process developed by the investigators. Step 1 of decision-making involved visualisation of the VP sphincter function by nasoendoscopy. This was followed by step 2 which involved per-operative identification of scarring, tissue loss, hypoplasia and other structural deficiencies in the soft palate and septal mucoperiosteum. The choice of operation was then made from a repertoire of interrelated and escalating surgical procedures consisting of palate revision and pharyngoplasties ranging from most anatomical to the least.

MAIN OUTCOME MEASURES

Evidence of postoperative restoration of VP function on nasoendoscopy, evaluation of speech for hypernasality, understandability, acceptability and symptoms of obstructive sleep apnea.

RESULTS

Complete VP closure was demonstrated in 94% of patients treated using this algorithm. There was significant improvement in all speech parameters (p < 0.00001).

CONCLUSION

Our comprehensive decision-making process is designed to effectively correct structural VPD according to the severity of structural and functional deficiencies in the soft palate and avoid over treatment.

Do Adult Naïve Listeners Perceive Differences in Speech Before and After Therapy for Cleft Palate Speech Disorders? A Reliability Study of Perceptual Speech Ratings

PURPOSE

This study compared the interrater reliability of adult naïve listeners' perceptual assessments of different speech variables in children with a cleft palate with or without a cleft lip (CP ± L). In addition, the study investigated whether the listeners were able to perceive differences in these speech variables before and after speech therapy for cleft palate speech disorders.

METHOD

Thirty-four speech samples of 14 children with a CP ± L (14 samples collected immediately before 10 hr of speech intervention, 14 samples collected immediately after speech intervention, and six randomly selected samples that were duplicated to assess intrarater reliability) were perceptually assessed by 26 adult naïve listeners. The listening panel consisted of nine men and 17 women (age range: 18-51 years). The speech variables included speech understandability, speech acceptability, hypernasality, hyponasality, nasal airflow, and articulation, which were assessed on a visual analog scale. Furthermore, the need for speech therapy was assessed.

RESULTS

Good to very good interrater reliability was observed for the naïve listeners' ratings of all speech variables. A significant time effect was found for the pre- and postevolution of the speech variables "speech understandability," "speech acceptability," "nasal airflow," and "articulation." This time effect indicates an improvement of these variables postintervention. According to the naïve listeners, children were less in need of additional speech therapy after the 10-hr intervention period compared to assessments before this intervention period.

CONCLUSIONS

Adult naïve listeners perceptually identified an improvement in different speech variables after 10 hr of cleft palate speech therapy. These findings confirm previous assessments of expert speech-language pathologists and suggest that speech improvements after cleft palate speech therapy can also be perceived by communication partners outside the therapy room. Perceptual ratings of naïve listeners can, thus, be used to add life-situation significance to the assessments of experts. Future research could include both expert raters and caregivers or relatives of children with a CP ± L in listening panels, as previous knowledge on craniofacial anomalies may lead to different results.

Do Buccal Flaps Improve Velopharyngeal Insufficiency in Conversion Furlow Palatoplasty for Patients with Cleft Palate?

SUMMARY

Velopharyngeal insufficiency (VPI) is a complication following primary palatoplasty that can lead to hypernasality of the voice and other speech problems. The conversion Furlow palatoplasty for VPI can be performed with the addition of buccal flaps to provide additional tissue for palatal repair. In this study, the authors aimed to determine the effectiveness of buccal flaps with conversion Furlow palatoplasty in secondary management of VPI. A retrospective review of patients undergoing surgical repair of VPI between 2016 and 2020 was performed. Patients underwent either conversion Furlow palatoplasty alone (FA) or conversion Furlow palatoplasty with buccal flaps (FB) for VPI after primary straight-line repair of the palate. The authors reviewed medical records to collect demographics, operative information, and preoperative and postoperative speech scores. Of the 77 patients in the study, 16 (21%) had a revision that incorporated buccal flaps. The median age at cleft palate revision surgery was 8.97 years in the FA group and 7.96 years in the FB group ( P = 0.337). In the FA group, four patients (7%) developed a postoperative fistula, compared with zero patients in the FB group. The average time to follow-up after revision surgery was 3.4 years (range, 7 months to 5.9 years). Both cohorts demonstrated a decrease in hypernasality and total parameter scores postoperatively. The use of buccal flaps in revision Furlow palatoplasty could decrease the risk for postoperative complications. The use of data from a larger patient population from multiple institutions is warranted to determine true significance.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, III.

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.

Exploring Reliable and Identifiable Quantitative Anatomical, Timing, and Displacement Measures in the VFS of Speech

AIM

Videofluroscopy studies of speech are a recognized assessment of velopharyngeal insufficiency (VPI). Yet, this method is subjective and has low inter-rater reliability. Quantitative measures of timing, distance, and area in videofluoroscopic studies of swallowing have been shown to be valid and reliable, but quantitative measures are not routinely used in videofluroscopy studies for VPI. This study explored the use of quantitative measures in patients with VPI in terms of feasibility and reliability.

METHODS

Forty patients of mixed etiology diagnosed with VPI through perceptual speech assessment underwent videofluroscopy. Anatomical landmarks and timing, distance, and area measurements were taken of the velopharyngeal port at rest and during speech tasks using specialized Swallowtail software. 50% of measures were double-blind rated to test inter-rater reliability. Raters reported on the time they took to complete each assessment and the challenges they had. Associations between measures were explored.

RESULTS

Ten timing, line, and area measures were developed based on 3 landmarks. Measures had moderate-substantial inter-rater reliability (intraclass coefficient: 0.69-0.91) except for time to lift (secs), which only achieved fair agreement (intraclass coefficient: 0.56). Measures demonstrated internal consistency ( R >0.60). Raters took, on average, 15 mins per patient and reported some challenges with image resolution, especially in timing measures where structures were blurred by movement.

CONCLUSION

Quantitative measures are reliable and have the potential to add novel information regarding VPI to support multidisciplinary decision-making. Further research with larger patient cohorts is needed to clarify how quantitative measures can support tailored decisions about surgical and therapeutic interventions in order to maximize outcomes for individuals.

Speech correcting surgery after primary palatoplasty: a systematic literature review and meta-analysis

OBJECTIVES

In cleft palate patients, the soft palate is commonly closed using straight-line palatoplasty, Z-palatoplasty, or palatoplasty with buccal flaps. Currently, it is unknown which surgical technique is superior regarding speech outcomes. The aim of this review is to study the incidence of speech correcting surgery (SCS) per soft palatoplasty technique and to identify variables which are associated with this outcome.

MATERIALS AND METHODS

A systematic literature search was carried out according to the PRISMA guidelines. Inclusion and exclusion criteria were applied to focus on the incidence of SCS after soft palatoplasty. Additional variables like surgical modification, cleft morphology, syndrome, age at palatoplasty, fistula and assessment of velopharyngeal function were reported. A modified New-Ottawa Scale (NOS) was used for quality appraisal. Pooled estimates from the meta-analysis were calculated using a random-effects model.

RESULTS

One thousand twenty-nine studies were found of which 54 were included in the analysis. The pooled estimate proportion of SCS after straight-line palatoplasty was 19% (95% CI 15-24), after Z-palatoplasty 6% (95% CI 4-9), and after palatoplasty with buccal flaps 7% (95% CI 4-11).

CONCLUSIONS

A lower SCS rate was found in patients receiving Z-palatoplasty when compared to straight-line palatoplasty. We propose a minimum set of outcome parameters which ideally should be included in future studies regarding speech outcomes after cleft palate repair.

CLINICAL RELEVANCE

Current literature reports highly heterogenous data regarding cleft palate repair. Our recommended set of parameters may address this inconsistency and could make intercenter comparison possible and of better quality.

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.

Treatment Outcomes of Interdisciplinary Care on Speech and Health-Related Quality of Life Outcomes in Adults With Cleft Palate

PURPOSE

Individuals born with a cleft palate with or without a cleft lip (CP ± L) often experience functional, aesthetic, and psychosocial consequences well into adulthood. This study aimed to investigate outcomes of speech and health-related quality of life (HRQoL) in adults with a CP ± L who received interdisciplinary cleft care at the Ghent University Hospital using valid, reliable, and condition-specific instruments.

METHOD

Thirteen Belgian Dutch-speaking participants with a CP ± L with a mean age of 25.4 years (SD = 5.1, range: 20-33 years) and an age- and gender-matched control group of 13 participants without a CP ± L with a mean age of 25.2 years (SD = 4.8, range: 20-32 years) were included in this study. Speech characteristics were evaluated perceptually and instrumentally. HRQoL was assessed through standardized patient-reported outcome measures. Outcomes were compared with those of the control group and to normative data where available.

RESULTS

Participants with a CP ± L in this sample demonstrated significantly lower speech acceptability (p < .001) and higher rates of hypernasality (p = .015) and nasal turbulence (p = .005) than the control group. They showed significantly higher satisfaction with appearance of the cleft scar compared with norms of adults with a CP ± L (p = .047). No other differences in speech characteristics, sociodemographics, or HRQoL were found between participants with and without a CP ± L.

CONCLUSIONS

The reduced speech acceptability and the presence of resonance and nasal airflow disorders may indicate the need for standardized long-term outcome measurement and interdisciplinary follow-up for speech characteristics and velopharyngeal insufficiency in young and middle adulthood in future clinical practice. Additional research is necessary to further substantiate these findings and to determine predictors for these continuing complications in adults with a CP ± L.

SUPPLEMENTAL MATERIAL

https://doi.org/10.23641/asha.24243901.

Prognostic Factors for Speech Outcome among Patients with Submucous Cleft Palate Managed by Furlow Palatoplasty or Posterior Pharyngeal Flap

BACKGROUND

Submucous cleft palate (SMCP) is a particular subtype of cleft deformity for which the optimal surgical timing and technique are still under debate. This study aimed to identify potential prognostic factors for the speech outcome of patients with SMCP and provide evidence for further management strategy optimization.

METHODS

The authors reviewed patients with nonsyndromic SMCP who received either Furlow palatoplasty (FP) or posterior pharyngeal flap (PPF) between 2008 and 2021 in a tertiary hospital-based cleft center. Both univariate and multivariate logistic regression models were used to screen preoperative variables, including cleft type (overt or occult), age at surgery, mobility of velum and pharyngeal wall, velopharyngeal closure ratio, and pattern. The receiver operating characteristic curve was used to determine the cutoff value of the significant predictors for subgroup comparison.

RESULTS

A total of 131 patients were enrolled, with 92 receiving FP and 39 receiving PPF. Age at operation and cleft type were identified as having significant effects on FP outcome. Patients operated on before 9.5 years of age had a significantly higher velopharyngeal competence (VPC) rate than those operated on after that age. The speech outcome among patients with occult SMCP was significantly worse than that of patients with overt SMCP after FP treatment. No preoperative variable was found to be correlated with PPF outcome. PPF yielded a higher VPC rate than did FP among patients operated on after 9.5 years of age.

CONCLUSIONS

The prognosis of patients with SMCP treated with FP is sensitive to age at surgery and cleft type. PPF may be considered for older patients in settings with limited access to multiple surgical procedures, especially when occult SMCP is diagnosed.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, III.

Speech Telepractice and Treatment Intensity in a Cantonese-Speaking Case with 22q11.2 Deletion Syndrome Following Late Diagnosis and Management of Velopharyngeal Dysfunction

This case report explores clinical treatment efficacy in a Cantonese-speaking child with 22q11.2 Deletion Syndrome where diagnosis and management of velopharyngeal dysfunction can be considered late. All treatment sessions were undertaken via telepractice during the peak of the COVID-19 pandemic in Hong Kong. A hybrid of specialized cleft palate speech treatment techniques and traditional treatment approaches in Speech Sound Disorders were utilized. Treatment intensity components including dose, dose form, session duration, and total intervention duration were documented.

Pharyngeal Flap Versus Sphincter Pharyngoplasty for the Treatment of Velopharyngeal Insufficiency in 22q11.2 Deletion Syndrome: Preliminary Findings From a Systematic Review

The purpose of this study was to examine and compare surgical and speech outcomes of the posterior pharyngeal flap and sphincter pharyngoplasty following surgical management of velopharyngeal insufficiency in patients with 22q11.2 deletion syndrome (22q11.2DS). This systematic review followed the Preferred Reporting Items for Systematic Review and Meta-Analyses checklist and guidelines. Selected studies were chosen using a 3-step screening process. The 2 primary outcomes of interest were speech improvement and surgical complications. Preliminary findings based on included studies suggest a slightly higher rate of postoperative complications with the posterior pharyngeal flap in patients with 22q11.2DS but a lower percentage of patients needing additional surgery compared with the sphincter pharyngoplasty group. The most reported postoperative complication was obstructive sleep apnea. Results from this study provide some insight into speech and surgical outcomes following pharyngeal flap and sphincter pharyngoplasty in patients with 22q11.2DS. However, these results should be interpreted with caution due to inconsistencies in speech methodology and lack of detail regarding surgical technique in the current literature. There is a significant need for standardization of speech assessments and outcomes to help optimize surgical management of velopharyngeal insufficiency in individuals with 22q11.2DS.

Effect of perceptive-auditory training on the classification of speech hypernasality

PURPOSE

To analyze the effect of auditory-perceptual training by inexperienced speech-language pathologists in the classification of hypernasality in individuals with cleft lip and palate and compare their classification of hypernasality individually, with the gold standard evaluation, before and after this training.

METHODS

Three inexperienced speech-language pathologists used a four-point scale to assess 24 high-pressure speech samples from individuals with cleft lip and palate, before and after auditory-perceptual training. The speech samples corresponded to six samples of each degree of hypernasality. The speech-language pathologists received auditory-perceptual training during the assessments. They had access to anchor samples and immediate feedback of correct answers regarding the degree of hypernasality in training.

RESULTS

There was no significant difference in the overall percentage of correct answers when comparing before and after the auditory-perceptual training. There was a significant association and agreement of the three evaluators with a gold standard evaluation after training, with an increase in agreement for a single evaluator for absent and mild degrees of hypernasality. The dichotomous analysis of the data showed an increase in the Kappa Index of Agreement of this evaluator. Although there was an increase in the Index of Agreement between evaluators for absent, mild, and severe hypernasality, this increase did not reach statistical significance.

CONCLUSION

The auditory-perceptual training provided did not result in a significant improvement in the hypernasality classification for the inexperienced speech-language pathologists, even though the individual data analysis showed that the training favored one of the evaluators. Further studies involving gradual and more extensive auditory-perceptual training may favor the classification of hypernasality by inexperienced SLPs.

Speech Outcomes and Velopharyngeal Function in Children Undergoing Submucous Cleft Palate Repair

OBJECTIVE

Describe and compare the results of speech and velopharyngeal function in children with classic and occult submucous cleft palate undergoing interdisciplinary treatment at the Gantz Foundation.

METHODS

The clinical history of all patients born between 2012 and 2017 with a diagnosis of classic or occult submucous cleft palate was retrospectively reviewed. Preoperative and postoperative medical, surgical, and speech and language history were collected.

RESULTS

Twenty-eight cases diagnosed at the age of 44.8±23.9 months were included. Of these, 71.4% presented classic submucous cleft, and 28.6% occult. Before primary surgery, 7.1% had a diagnosis of the syndrome, and 21.4% were under study. A total of 39.3% had hearing difficulties and 21.4% used tympanic ventilation tubes. A total of 60.7% had language problems, 39.3% had compensatory articulation, 17.9% had absent hypernasality, and 21.4% had absent nasal emission. The team indicated primary palate surgery in 71.4%, of which 85% performed the surgery at the mean age of 61.7±24.7 months. The surgical technique was Furlow in 88.2% of the cases and intravelar veloplasty in the remaining 11.8%. Then, 3 cases underwent velopharyngeal insufficiency surgery; 2 of them eliminated hypernasality and reduced nasal emission. The age of diagnosis ( P =0.021) and the performance of velopharyngeal insufficiency surgery ( P =0029) of the occult submucous cleft palate group was significatively later than the classic cleft palate group.

CONCLUSIONS

Language, hearing, compensatory articulation, hypernasality, and nasal emission problems were recorded. A high percentage required primary surgery. Of these, a low proportion also required a velopharyngeal insufficiency surgery, which improved the velopharyngeal function of the children but did not completely adapt it. In this regard, early diagnosis is essential, as well as an analysis of each center primary closure protocol.

Subjective and Objective Evaluation of Speech in Adult Patients With Repaired Cleft Palate

OBJECTIVE

To explore the speech outcomes of adult patients with repaired cleft palate through subjective perception evaluation and objective acoustic analysis, and to compare the differences in pronunciation characteristics between speakers with complete velopharyngeal closure (VPC) and velopharyngeal insufficiency (VPI) patients.

PARTICIPANTS AND INTERVENTION

Subjective evaluation indicators included speech intelligibility, nasality and consonant missing rate, for objective acoustic analysis, we used speech sample normalization and objective acoustic parameters included normalized vowel formants, voice onset time and the analysis of 3-dimensional spectrogram and spectrum, were carried out on speech samples produced by 3 groups of speakers: (a) speakers with velopharyngeal competence after palatorrhaphy (n=38); (b) speakers with velopharyngeal incompetence after palatorrhaphy (n=70), (c) adult patients with cleft palate (n=65) and (d) typical speakers (n=30).

RESULTS

There was a highly negative correlation between VPC grade and speech intelligibility (ρ=-0.933), and a highly positive correlation between VPC and nasality (ρ=0.813). In subjective evaluation, the speech level of VPI patients was significantly lower than that of VPC patients and normal adults. Although the nasality and consonant loss rate of VPC patients were significantly higher than that of normal adults, the speech intelligibility of VPC patients was not significantly different from that of normal adults. In acoustic analysis, patients with VPI still performed poorly compared with patients with VPC.

CONCLUSIONS

The speech function of adult cleft palate patients is affected by abnormal palatal structure and bad pronunciation habits. In subjective evaluation, there was no significant difference in speech level between VPC patients and normal adults, whereas there was significant difference between VPI patients and normal adults. The acoustic parameters were different between the 2 groups after cleft palate repair. The condition of palatopharyngeal closure after cleft palate can affect the patient's speech.

Evaluation of late cleft palate repair by a modified technique without relaxing incisions

OBJECTIVE

To evaluate the postoperative outcomes together with analyzing the associated influencing factors following a late cleft palate repair by the Sommerlad-Furlow modified technique (S-F).

MATERIALS AND METHODS

In a retrospective cohort, 320 consecutive patients with cleft palate, who received S-F technique between 2011 and 2017, were reviewed. The patients were divided into three age groups, less than one year (143), one to two years (113), and greater than 2 years (64). The postoperative outcomes included wound healing (complete/fistula) and velopharyngeal function (VPF).

RESULTS

The overall cleft width was 10 ± 3.07 mm. The overall rates of complete wound healing and proper velopharyngeal function were 96.6% and 81.56%, respectively. No significant difference was found between the age groups regarding wound healing, with an overall fistula rate of 3.4%. The VPF was significantly varied among the age groups (P<0.001). In context, the rates of velopharyngeal insufficiency (VPI) were 9.8%, 14.2%, and 45.4% among patients repaired at ˂1, 1-2, and >2 years old, respectively. The cleft type was the most potential factor associated with fistula. The age at repair was identified as the most implicating factor for VPI.

CONCLUSIONS

The S-F technique had achieved low fistula rate and satisfactory speech outcome, especially in early repair group and even in the wide cleft palate. The older age at repair and severe cleft type had a major impact on the postoperative outcomes.

Myanmar Articulation, Resonation, Nasal Emission, and Nasal Turbulence Test: A Preliminary Study

Background  This article describes the development of the Myanmar Articulation, Resonation, Nasal Emission, and Nasal Turbulence test for children with cleft lip and palate (CLP), and evaluation of its validity and reliability. Methods  It was created by three Thai researchers and a Burmese research assistant based on Burmese phonology. The content validity was evaluated by six Burmese language experts. All test items were divided into three groups: high-pressure oral consonants, low-pressure oral consonants, and nasal consonants. Results  All items (58-word and 32-phrase/sentence) gave an excellent level of the expert agreement (item-level content validity indexes = 1.00). The target items were illustrated as color pictures. Each picture was clearly drawn and easy to identify. As a pilot study of face validity, all pictures were administered to 10 typical-developing children. The actual testing was assessed by 10 CLP children, and the developed test was analyzed through consultation of the Burmese teachers and interpreters from a speech camp. Testing scores for a total including three groups of target items were shown acceptable for internal consistency reliability (ranged from 0.4 to 0.88). Conclusion  The constructed test is valid in terms of its content.