Achados clínicos fonoaudiológicos em adolescente com diabetes melittus tipo I: relato de caso / Speech-language pathology findings in adolescent with type I diabetes mellitus: a case report / Hallazgos de patología del habla y lenguaje en un adolescente con diabetes mellitus tipo I: reporte de un caso

Introdução: O diabetes mellitus tipo 1 (DM1) se caracteriza pela destruição das células beta das ilhotas pancreáticas, manifestando-se em hiperglicemia sintomática, devido a um déficit absoluto de insulina, gerando dependência vital de insulina exógena. É considerado típico em crianças e adolescentes; entretanto, pode se desenvolver em qualquer idade. Há inúmeros achados de alterações auditivas em pessoas com DM1, porém não há estudos em outras áreas da Fonoaudiologia. Objetivo: relatar o caso de um adolescente com diagnóstico recente de diabetes mellitus tipo I e alterações fonoaudiológicas na área da fala - desvio fonético no fonema /r/ - e de processamento auditivo. Apresentação do caso: Adolescente de 11 anos de idade vem encaminhado para Fonoaudiologia por não conseguir executar o /r/, com histórico de atendimento fonoaudiológico prévio. Logo após avaliação de fala e início do tratamento, realizou exame de processamento auditivo, que apontou alteração. Após 30 sessões de fonoterapia, o processamento auditivo foi tratado com sucesso. Discussão: Os achados do caso corroboram com o descrito na literatura consultada. Conclusão: O presente estudo se faz pertinente devido à escassez de estudos com mais participantes, com outras áreas da Fonoaudiologia que não somente a Audiologia.

Introduction: Type 1 diabetes mellitus (DM1) is characterized by the destruction of beta cells of pancreatic islets, manifesting in symptomatic hyperglycemia, due to an absolute insulin deficit, generating vital dependence on exogenous insulin. It is considered typical in children and adolescents; however, it can develop at any age. There are countless findings of auditory alterations in people with DM1, but there are no studies in other areas of Speech-Language Pathology. Objective: to report the case of an adolescent with a recent diagnosis of type I diabetes mellitus and Speech-Language Pathology disorders in the speech area - phonetic deviation in the phoneme /r/ - and auditory processing. Case report: An 11-year-old teenager arrives at the Speech-Language Pathology department for not being able to perform the /r/. Right after speech assessment and treatment initiation, he underwent an auditory processing exam, which showed changes. After 30 sessions of speech therapy, auditory processing was successfully treated. Discussion: The findings of the case corroborate with those described in the consulted literature. Conclusion: The present study is relevant due to the scarcity of studies with more participants, with other areas of Brazilian Speech-Language Pathology, other than only Audiology.

Introducción: la diabetes mellitus tipo 1 (DM1) se caracteriza por la destrucción de las células beta de los islotes pancreáticos, que se manifiestan en hiperglucemia sintomática, debido a un déficit absoluto de insulina, lo que genera una dependencia vital de la insulina exógena. Se considera típico en niños y adolescentes; sin embargo, puede desarrollarse a cualquier edad. Existen innumerables hallazgos de alteraciones auditivas en personas con DM1, pero no hay estudios en otras áreas de la Fonoaudiología. Objetivo: informar el caso de un adolescente con un diagnóstico reciente de diabetes mellitus tipo I y trastornos de fonoaudiología en el área del habla - desviación fonética en el fonema / r / - y procesamiento auditivo. Caso clínico: un adolescente de 11 años llega a Fonoaudiología por no poder realizar el /r/, con antecedentes de terapia del habla previa. Inmediatamente después de la evaluación del habla y el inicio del tratamiento, se sometió a un examen de procesamiento auditivo, que mostró cambios. Después de 30 sesiones de terapia del habla, el procesamiento auditivo se trató con éxito. Discusión: Los hallazgos del caso corroboran con los descritos en la literatura consultada. Conclusión: El presente estudio es relevante debido a la escasez de estudios con más participantes, con otras áreas de la Fonoaudiología brasileña además de la Audiología.

Predicting speech-sound disorder outcomes in school-age children with hearing loss: The VicCHILD experience.

BACKGROUND: Congenital hearing loss is the most common birth anomaly, typically influencing speech and language development, with potential for later academic, social and employment impacts. Yet, surprisingly, the nuances of how speech is affected have not been well examined with regards to the subtypes of speech-sound disorder (SSD). Nor have the predictors of speech outcome been investigated within a sizeable population cohort. AIMS: (1) To describe the subtypes and prevalence of SSD in children with hearing loss. (2) To determine which characteristics of hearing loss predict the presence of SSD. METHODS & PROCEDURES: A total of 90 children (5-12 years of age) with permanent hearing loss were recruited from an Australian population cohort. Children completed a standardized speech assessment to determine the presence and subtype of SSD. Logistic regression was used to determine the predictors of speech outcome. Demographic, developmental and hearing-related predictors were examined. OUTCOMES & RESULTS: The prevalence of speech disorder overall was 58%, with the most common subtype being phonological delay in 49% of the sample. Factors most predictive of speech disorder were being male, younger and a bimodal user (i.e., using both a hearing aid and a cochlear implant). CONCLUSIONS & IMPLICATIONS: This is the first study, in a sizeable cohort, to describe the prevalence and predictive factors for SSD associated with hearing loss. Clinically, it could be beneficial to implement earlier targeted phonological interventions for children with hearing loss. What this paper adds What is already known on this subject Speech issues are common in children with hearing loss; however, the breakdown of subtypes of SSD (e.g., articulation versus phonological disorder) have not been previously described in a population cohort. This distinction is relevant, as each subtype calls for specific targeted intervention. Studies examining factors predictive of speech outcomes, across a range of hearing levels, are also lacking in a population cohort. What this paper adds to existing knowledge Data suggest the most common type of SSD in children with hearing loss is phonological delay. Males, younger children, and bimodal users were at greater risk of having a subtype of SSD. What are the potential or actual clinical implications of this work? The results are clinically pertinent as the speech diagnosis determines the targeted treatment. Phonological delay is responsive to treatment, and early targeted intervention may improve prognosis for speech outcomes for children with hearing loss.

Speech production in young children with tongue-tie.

INTRODUCTION: Tongue-tie, or ankyloglossia, occurs in 4-10% of the population. Treatment of tongue-tie has increased by 420% in Australia between 2006 and 2016 and 866% in the United States between 1997 and 2012. Despite limited evidence, it has been suggested that tongue-tie can result in speech sound disorder (SSD). This study aimed to investigate tongue mobility and speech production outcomes in children with and without tongue-tie diagnoses. METHOD: Fifty-nine children aged 2; 1 to 4; 11 years were recruited and formed three groups: treated tongue-tie (TTT), untreated tongue-tie (UTT) and no tongue-tie (NTT). Measures of lingual frenulum structure and function, tongue mobility, speech production, and parent and clinician intelligibility ratings were collected. RESULTS: No statistically significant differences were found between the TTT, UTT and NTT groups for tongue mobility, speech production or intelligibility. Significantly more UTT children had a history of speech pathology attendance than participants in the NTT group. CONCLUSION: This study provides preliminary evidence of no difference between tongue mobility and speech outcomes in young children with or without intervention for tongue-tie during infancy. This study assists with clinical decision making and makes recommendations for families not to proceed with surgical intervention for tongue-tie during infancy, for the sole outcome of improving speech production later in life.

Montgomery T-tube for management of tracheomalacia: Impact on voice-related quality of life.

INTRODUCTION: Tracheostomy is a common procedure for management of tracheomalacia. However, the limitation to speak related to tracheostomy cannula could affect the quality of life. OBJECTIVES: we reported a new minimally invasive procedure to replace tracheostomy cannula with Montgomery T-tube to improve the ability of speaking. METHODS: This is a single center study including all consecutive patients undergoing the replacement of standard tracheostomy cannula with T-tube for management of tracheomalacia. The end-points were to evaluate (a) the changes in Voice-related quality of Life (V-RQOL) before and after T-tube placement; and (b) the complications related to T-tube. RESULTS: Eleven patients were included in the study. T-tube was placed using flexible bronchoscopy and laryngeal mask airway. A suture was inserted through the proximal end of T-tube. Once the stent was introduced with a clamp into the trachea, a traction was applied on the suture to facilitate the alignment of the upper end of the stent. The comparison of V-RQOL values before and after T-tube insertion showed a significant improvement in social/emotional (39.2 ± 6.1 vs 66.8 ± 1.9; P = .0001); physical functioning (21 ± 5.7 vs 56.4 ± 5.3; P = 0.0001) and total V-RQOL scores (33.9 + 5.4 vs 61.3 + 6.1; P = 0.0001). No complications were seen during the insertion of the stent. In two patients, T-tube was obstructed by mucus that resolved with aspiration using flexible bronchoscopy (mean follow-up: 18 ± 10 months). CONCLUSIONS: Our technique is simple and safe, not needing specific skills and/or cumbersome devices. The replacement of tracheostomy cannula with T-tube seems to improve the quality of voice without adding major complications.

Exome Sequencing of Two Siblings with Sporadic Autism Spectrum Disorder and Severe Speech Sound Disorder Suggests Pleiotropic and Complex Effects.

Recent studies of autism spectrum disorder (ASD) and childhood apraxia of speech (CAS) have resulted in conflicting conclusions regarding the comorbidity of these disorders on phenotypic grounds. In a nuclear family with two dually affected and one unaffected offspring, whole-exome sequences were evaluated for single nucleotide and indel variants and CNVs. The affected siblings but not the unaffected sibling share a rare deleterious compound heterozygous mutation in WWOX, implicated both in ASD and motor control. In addition, one of the affected children carries a rare deleterious de novo mutation in the ASD candidate gene RIMS1. The two affected children but not their unaffected sibling inherited deleterious variants with relevance for ASD and/or CAS. WWOX, RIMS1, and several of the genes harboring the inherited variants are expressed in the brain during prenatal and early postnatal development. Results suggest compound heterozygosity as a cause of ASD and CAS, pleiotropic gene effects, and potentially additional, complex genetic effects.

Correlation between functional disorders of the masticatory system and speech sound disorders in children aged 7-10 years.

BACKGROUND: Masticatory system and speech sound disorders concur, have the same causes and similar consequences - both increase the risk of dental and periodontal diseases. OBJECTIVES: The study was conducted to establish the correlation between functional disorders of the masticatory system and speech sound disorders. MATERIAL AND METHODS: Three hundred patients aged 7-10 years were examined to detect functional disorders of the masticatory system and speech sound disorders. Functional disorders were assessed in patients with and without speech sound disorders. RESULTS: According to the study results, functional disorders of the masticatory system concur more often with speech sound disorders than with correct articulation and lead to speech sound disorders. There is a strong correlation between: - any dysfunction and errors in the /p/, /b/, /m/, /s/, /z/, /t͡ s/, /d͡ z/, /ɕ/, /ʑ/, /t͡ ɕ/, and /d͡ ʑ/ sounds, - mouth breathing and errors in the /p/, /b/, /m/, /s/, /z/, /t͡ s/, /d͡ z/, /ɕ/, /ʑ/, /t͡ ɕ/, and /d͡ ʑ/ sounds, - persistent tongue thrust and errors in the /s/, /z/, /t͡ s/, /d͡ z/, /ʂ/, /ʐ/, /t͡ ʂ/, /d͡ ʐ/, /ɕ/, /ʑ/, /t͡ ɕ/, and /d͡ ʑ/ sounds, and - parafunctional sucking and errors in the /s/, /z/, /t͡ s/, /d͡ z/, /ʂ/, /ʐ/, /t͡ ʂ/, /d͡ ʐ/, /ɕ/, /ʑ/, /t͡ ɕ/, and /d͡ ʑ/ sounds. CONCLUSIONS: To implement effective and early prevention and treatment, it is crucial to know the correlation between the masticatory system and speech sound disorders, as it reduces treatment duration and minimizes relapses of not only communication disorders, but also of concurrent masticatory system disorders.

The Effects of Palate Features and Glossectomy Surgery on /s/ Production.

Purpose: The aims of this article were to determine the effects of hard palate morphology and glossectomy surgery on tongue position and shape during /s/ for patients with small tumors. The first expectation was that laminal /s/ would be more prevalent in patients, than apical, due to reduced tongue tip control after surgery. The second was that patients would hold the tongue more anteriorly than controls to compensate for reduced tongue mass. Method: Three-dimensional tongue volumes were calculated from magnetic resonance imaging for the whole tongue and the portion anterior to the first molar during the /s/ in /əsuk/ for 21 controls and 14 patients. These volumes were used to calculate tongue anteriority and cross-sectional shape. Dental casts were used to measure palate perimeter, height, and width of the hard palate. Results: Palate height correlated with tongue height in controls (p < .05), but not patients. In patients, tongue anteriority correlated negatively with canine width and cross-sectional tongue shape (p < .05). Controls with a high palate favored laminal /s/. Patients preferred laminal /s/ regardless of palate height (p < .01). Conclusions: For controls, hard palate height affected tongue height; a higher palate yielded a higher tongue. For patients, hard palate width affected tongue width; a narrower palate yielded a more anterior tongue. Tongue shape was unaffected by any palate features. Preference for /s/ showed an interaction effect between subject and palate height. Controls with high palates preferred a laminal /s/. All patients preferred a laminal /s/; glossectomy surgery may reduce tongue tip control.

A Systematic Review of Speech Assessments for Children With Autism Spectrum Disorder: Recommendations for Best Practice.

PURPOSE: The purpose of this systematic review was to provide a summary and evaluation of speech assessments used with children with autism spectrum disorders (ASD). A subsequent narrative review was completed to ascertain the core components of an evidence-based pediatric speech assessment, which, together with the results of the systematic review, provide clinical and research guidelines for best practice. METHOD: A systematic search of eight databases was used to find peer-reviewed research articles published between 1990 and 2014 assessing the speech of children with ASD. Eligible articles were categorized according to the assessment methods used and the speech characteristics described. RESULTS: The review identified 21 articles that met the inclusion criteria, search criteria, and confidence in ASD diagnosis. The speech of prelinguistic participants was assessed in seven articles. Speech assessments with verbal participants were completed in 15 articles with segmental and suprasegmental aspects of speech analyzed. Assessment methods included connected speech samples, single-word naming tasks, speech imitation tasks, and analysis of the production of words and sentences. CONCLUSIONS: Clinical and research guidelines for speech assessment of children with ASD are outlined. Future comparisons will be facilitated by the use of consistent reporting methods in research focusing on children with ASD.

Do mandibular complete dentures made using a neutral zone technique improve speech?-A pilot study.

OBJECTIVE: The aim of this study was to evaluate speech sound production (SSP) in older edentulous patients provided with two different types of mandibular complete dentures (MCDs; conventional vs neutral zone). BACKGROUND: Regarding the fact that complete dentures (CDs) affect SSP, it is unknown whether the set-up of the artificial teeth resulting from the neutral zone technique leads to a negative impact on SSP. MATERIALS AND METHODS: For 21 participants, a conventional MCD and a MCD using a modified neutral zone technique (neutral zone dentures) were fabricated. The SSP was described using a phonetically balanced text, which was recorded digitally and evaluated. RESULTS: No significant difference in SSP was observed. CONCLUSION: Within the limits of this study, it can be concluded that the application of the neutral zone technique in the mandible has no considerable impact on SSP.

Phonoarticulation in spinocerebellar ataxia type 3.

Phonoarticulation is characterized by changes in resonance, diadochokinesis, prosody, sound frequency, vocal quality, and intraoral pressure. The main aim of this study was to characterize the phonoarticulation in spinocerebellar ataxia type 3 (SCA3) and correlate it with clinical and genetic factors. Thirty-one patients with SCA3 who were subjected to spontaneous speech recordings and phonoarticulatory diadochokinesis (DDK) participated in the study. Speech analyses were performed starting after 10 s of spontaneous speech, by three experienced speech therapists, using a protocol for dysarthria adapted from the Mayo Clinic. The intra-evaluator reliability was analyzed. The lower the patient's age at disease onset was, the more frequent the occurrences of monofrequency and altered speech rhythm were. Articulation, DDK, resonance, and prosody showed a moderate correlation with the number of "CAG" triplet repeats. We conclude that the phonoarticulation of patients with Machado-Joseph disease (MJD) is characterized by mixed dysarthrophonia with cerebellar and hypokinetic components, and that there is a tendency toward higher frequency of dysarthrophonia symptoms with lower age of disease onset, longer time since onset and higher number of "CAG" triplet repeats.

Evaluation of Speech and Resonance for Children with Craniofacial Anomalies.

Children with craniofacial anomalies often demonstrate disorders of speech and/or resonance. Anomalies that affect speech and resonance are most commonly caused by clefts of the primary palate and secondary palate. This article discusses how speech-language pathologists evaluate the effects of dental and occlusal anomalies on speech production and the effects of velopharyngeal insufficiency on speech sound production and resonance. How to estimate the size of a velopharyngeal opening based on speech characteristics is illustrated. Nasometry, nasopharyngoscopy, and low-tech tools are discussed as adjunct methods to aid in the evaluation, treatment planning, and measurement of outcomes.

The influence of (central) auditory processing disorder on the severity of speech-sound disorders in children.

OBJECTIVE: To identify a cutoff value based on the Percentage of Consonants Correct-Revised index that could indicate the likelihood of a child with a speech-sound disorder also having a (central) auditory processing disorder . METHODS: Language, audiological and (central) auditory processing evaluations were administered. The participants were 27 subjects with speech-sound disorders aged 7 to 10 years and 11 months who were divided into two different groups according to their (central) auditory processing evaluation results. RESULTS: When a (central) auditory processing disorder was present in association with a speech disorder, the children tended to have lower scores on phonological assessments. A greater severity of speech disorder was related to a greater probability of the child having a (central) auditory processing disorder. The use of a cutoff value for the Percentage of Consonants Correct-Revised index successfully distinguished between children with and without a (central) auditory processing disorder. CONCLUSIONS: The severity of speech-sound disorder in children was influenced by the presence of (central) auditory processing disorder. The attempt to identify a cutoff value based on a severity index was successful.

The influence of (central) auditory processing disorder on the severity of speech-sound disorders in children

OBJECTIVE: To identify a cutoff value based on the Percentage of Consonants Correct-Revised index that could indicate the likelihood of a child with a speech-sound disorder also having a (central) auditory processing disorder . METHODS: Language, audiological and (central) auditory processing evaluations were administered. The participants were 27 subjects with speech-sound disorders aged 7 to 10 years and 11 months who were divided into two different groups according to their (central) auditory processing evaluation results. RESULTS: When a (central) auditory processing disorder was present in association with a speech disorder, the children tended to have lower scores on phonological assessments. A greater severity of speech disorder was related to a greater probability of the child having a (central) auditory processing disorder. The use of a cutoff value for the Percentage of Consonants Correct-Revised index successfully distinguished between children with and without a (central) auditory processing disorder. CONCLUSIONS: The severity of speech-sound disorder in children was influenced by the presence of (central) auditory processing disorder. The attempt to identify a cutoff value based on a severity index was successful.

The influence of (central) auditory processing disorder in speech sound disorders / Influência do transtorno do processamento auditivo (central) no transtorno fonológico

ABSTRACT INTRODUCTION: Considering the importance of auditory information for the acquisition and organization of phonological rules, the assessment of (central) auditory processing contributes to both the diagnosis and targeting of speech therapy in children with speech sound disorders. OBJECTIVE: To study phonological measures and (central) auditory processing of children with speech sound disorder. METHODS: Clinical and experimental study, with 21 subjects with speech sound disorder aged between 7.0 and 9.11 years, divided into two groups according to their (central) auditory processing disorder. The assessment comprised tests of phonology, speech inconsistency, and metalinguistic abilities. RESULTS: The group with (central) auditory processing disorder demonstrated greater severity of speech sound disorder. The cutoff value obtained for the process density index was the one that best characterized the occurrence of phonological processes for children above 7 years of age. CONCLUSION: The comparison among the tests evaluated between the two groups showed differences in some phonological and metalinguistic abilities. Children with an index value above 0.54 demonstrated strong tendencies towards presenting a (central) auditory processing disorder, and this measure was effective to indicate the need for evaluation in children with speech sound disorder.

RESUMO INTRODUÇÃO: Considerando a importância das informações recebidas auditivamente para a aquisição e organização das regras fonológicas, a avaliação do processamento auditivo (central) traz contribuições significativas para o diagnóstico e direcionamento da intervenção fonoaudiologia das crianças com transtorno fonológico. OBJETIVO: Estudar as medidas fonológicas e o processamento auditivo (central) de crianças com transtorno fonológico. MÉTODO: Estudo clínico e experimental com 21 sujeitos com transtorno fonológico, entre 7,0 e 9,11 anos, separados em dois grupos: com e sem transtorno do processamento auditivo (central). Foram avaliadas as provas de fonologia, inconsistência de fala e habilidades metalinguísticas. RESULTADOS: O grupo com transtorno do processamento auditivo (central) apresentou maior gravidade do transtorno fonológico. O valor de corte obtido para o process density index foi o que melhor caracterizou a ocorrência dos processos fonológicos para crianças acima de sete anos. CONCLUSÃO: A comparação do desempenho das provas avaliadas nos dois grupos mostrou diferenças quanto a alguns aspectos fonológicos e metalinguísticas. As crianças com valor do índice acima de 0,54 demonstraram uma forte tendência a apresentar alteração no processamento auditivo (central), sendo que esta medida foi efetiva para indicar a necessidade de avaliação de crianças com transtorno fonológico.

The influence of (central) auditory processing disorder in speech sound disorders.

INTRODUCTION: Considering the importance of auditory information for the acquisition and organization of phonological rules, the assessment of (central) auditory processing contributes to both the diagnosis and targeting of speech therapy in children with speech sound disorders. OBJECTIVE: To study phonological measures and (central) auditory processing of children with speech sound disorder. METHODS: Clinical and experimental study, with 21 subjects with speech sound disorder aged between 7.0 and 9.11 years, divided into two groups according to their (central) auditory processing disorder. The assessment comprised tests of phonology, speech inconsistency, and metalinguistic abilities. RESULTS: The group with (central) auditory processing disorder demonstrated greater severity of speech sound disorder. The cutoff value obtained for the process density index was the one that best characterized the occurrence of phonological processes for children above 7 years of age. CONCLUSION: The comparison among the tests evaluated between the two groups showed differences in some phonological and metalinguistic abilities. Children with an index value above 0.54 demonstrated strong tendencies towards presenting a (central) auditory processing disorder, and this measure was effective to indicate the need for evaluation in children with speech sound disorder.

Differential Diagnosis of Speech Sound Disorder (Phonological Disorder): Audiological Assessment beyond the Pure-tone Audiogram.

BACKGROUND: According to the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, diagnosis of speech sound disorder (SSD) requires a determination that it is not the result of other congenital or acquired conditions, including hearing loss or neurological conditions that may present with similar symptomatology. PURPOSE: To examine peripheral and central auditory function for the purpose of determining whether a peripheral or central auditory disorder was an underlying factor or contributed to the child's SSD. RESEARCH DESIGN: Central auditory processing disorder clinic pediatric case reports. STUDY SAMPLE: Three clinical cases are reviewed of children with diagnosed SSD who were referred for audiological evaluation by their speech-language pathologists as a result of slower than expected progress in therapy. RESULTS: Audiological testing revealed auditory deficits involving peripheral auditory function or the central auditory nervous system. These cases demonstrate the importance of increasing awareness among professionals of the need to fully evaluate the auditory system to identify auditory deficits that could contribute to a patient's speech sound (phonological) disorder. CONCLUSIONS: Audiological assessment in cases of suspected SSD should not be limited to pure-tone audiometry given its limitations in revealing the full range of peripheral and central auditory deficits, deficits which can compromise treatment of SSD.

Effectiveness of tongue-tie division for speech disorder in children.

BACKGROUND: The aim of this study was to determine the effectiveness of tongue-tie division (frenuloplasty/ frenulotomy) for speech articulation disorder in children with ankyloglossia (tongue-tie). METHODS: Articulation test was done in five children (3-8 years old) with speech problems who underwent tongue-tie division. The test consisted of 50 pictures of common Japanese words with 2-3 syllables. The patients were interviewed by a speech therapist and asked to pronounce what the picture card showed. Misarticulations of substitution, omission, and distortion were assessed. The preoperative results were compared with postoperative examinations at 1 month, 3-4 months, and 1-2 years. RESULTS: Nineteen substitutions that were observed in four patients preoperatively decreased to 10 in three patients at 1 month, 7 in three patients at 3-4 months, and 1 in one patient at 1-2 years postoperatively. Five omissions that were observed in four patients preoperatively decreased to 3 in three patients at 1 month, 2 in two patients at 3-4 months, and 1 in one patient at 1-2 years postoperatively. Thirteen distortions that were observed in five patients preoperatively decreased to 8 in four patients at 3-4 months but increased to 11 in three patients at 1-2 years postoperatively. CONCLUSIONS: Substitution and omission improved relatively early after tongue-tie division and progressed to distortion, which is a less-impaired form of articulation disorder. Thus, distortion required more time for improvement and remained a defective speaking habit in some patients.