Speech Outcomes Audit for Unilateral Cleft lip and Palate After 2-Stage Palate Repair: Preliminary Results.

Primary cleft lip and palate surgeries can interfere with speech status, facial appearance, maxillary growth, and psychosocial and academic development. Therefore, different surgical protocols and techniques have been proposed, and adequate velopharyngeal function and speech is the main goal for the treatment success. The present study aimed to report preliminary speech results of the 2-stage palate repair of children with unilateral cleft lip and palate. One hundred seventy nonsyndromic patients with unilateral cleft lip and palate were included in this report, 35% males and 65% females, submitted to the 2-stage palatoplasty protocol, composed by lip, nasal ala, and hard palate repair at 3 to 6 m (stage 1) and soft palate repair at 12 to 18 m (stage 2). The target age range for speech recording was 5 to 10 years, and the speech material included repetition of Brazilian Portuguese sentences. These samples were obtained over 5 years and assessed by 3 of 14 experienced speech pathologists. When discordant, the majority rate was adopted. Average velopharyngeal dysfunction (VPD) rates were 19,5%, varying according to the soft palate technique, with better results when the Sommerlad technique was performed (VPD=11%), followed by Braithwaite (VPD=15%) and then Von Langenbeck (VPD=25%). Passive errors were observed in 32% and active errors in 25%. Speech results reflect the outcomes of an interdisciplinary team's work, where facial growth and nasolabial appearance must also be considered. Further analysis and a wider casuistic are recommended. Hence outcomes audit needs to be a permanent process, providing solid and updated evidence for optimal cleft care.

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.

Effect of Orthognathic Surgery on Breathing in Patients with Cleft lip and Palate: 20-Year Experience at a Tertiary Hospital in Brazil.

OBJECTIVE: To verify the effect of orthognathic surgery (OS) on nasal dimensions and its correlation with respiratory symptoms in patients operated on over the past 20 years. DESIGN: Retrospective study. SETTING: Tertiary level craniofacial hospital. PARTICIPANTS: 535 patients with CLP previously repaired, without syndromes, age over 18, who performed OS between 2000 and 2019 and rhinomanometric evaluation pre and post OS. INTERVENTIONS: Maxillary advancement isolated and combined with turbinectomy and/or mandibular osteotomy. MAIN OUTCOME MEASURES: Minimum nasal cross-sectional area (CSA) assessed by posterior (PR) and anterior rhinomanometry (AR), nasopharyngeal cross-sectional area (NCSA) verified by modified AR, and self-perceived respiratory symptoms through a questionnaire. RESULTS: After OS, there was a significant increase in CSA assessed by PR (p < .001) and AR (p < .001), while there was no significant difference in NCSA (p = 0.319). Regarding respiratory symptoms after OS, 26.3% showed improvement in nasal obstruction, 28.5% in oronasal breathing, 18.5% in snoring, and 5.2% in respiratory obstruction during sleep. However, a weak correlation between increased CSA and improvement of symptoms was observed. In the first decade, lower values of CSA (p < .001) and NCSA (p < .001) were observed compared to the second decade. Both periods showed a significant increase in CSA (p < .001). CONCLUSIONS: Nasal dimensions and breathing symptoms were improved by OS when combined with turbinectomy. Comparing the results of patients operated on between two different decades, patients had more favorable conditions for breathing in the most recent decade of care. However, this was not statistically correlated with the improvement in patient symptoms in this study.

Facial grimace during speech in cleft lip and palate: a proposal for classification. / Mímica facial durante a fala em fissura labiopalatina: uma proposta de classificação.

PURPOSE: To investigate the effectiveness of a proposal for classification of facial grimace (FG) and its correlation with objective evaluation of velopharyngeal closure (VPC). METHODS: Twenty individuals with repaired cleft lip and palate underwent velopharyngeal area measurement by means of rhinomanometry and speech sample recording. The FG was rated in two steps, by three speech-language pathologists. First the evaluators rated the FG using their own criteria as: 1= absent FG; 2=mild; 3=moderate; 4=severe. Subsequently, they were submitted to a training session that established the following FG rating criteria: 1=absent FG; 2=movement only of the nose or upper third of the face; 3=strong movement of the nose or upper third of the face; 4=movement of the nose and upper third of the face. The evaluators rated the FG using the established criteria. Intra- and inter-rater agreement were calculated using weighted Kappa coefficient. Correlation between the two stage ratings with the VPC was calculated by Spearman's correlation coefficient. RESULTS: In the first stage inter-rater agreement ranged from fair to substantial; in the second stage, from substantial to almost perfect. Intra-rater agreement ranged from moderate to almost perfect in the first stage, and from moderate to substantial in the second stage. The correlation between FG and velopharyngeal area was positive and significant in both stages. CONCLUSION: The proposed FG judgement proved to be effective in determining the symptom and reliable in diagnosing the severity of velopharyngeal dysfunction. The significant correlation between perceptual and instrumental methods suggests that FG can be used in predicting VPC.

OBJETIVO: Investigar a efetividade de proposta de classificação da mímica facial (MF), e sua correlação com avaliação objetiva do fechamento velofaríngeo (FVF). MÉTODO: Vinte indivíduos com fissura labiopalatina reparada foram submetidos à medida da área velofaríngea por meio da rinomanometria e à gravação de amostra de fala. A MF foi classificada em dois momentos, por três fonoaudiólogas. Inicialmente as avaliadoras classificaram a MF, utilizando critérios próprios, em: 1=MF ausente; 2=leve; 3=moderada; 4=grave. Posteriormente, foram submetidas a um treinamento com o estabelecimento dos seguintes critérios de classificação: 1=MF normal; 2=movimento somente de nariz ou terço superior da face; 3=movimento acentuado de nariz ou terço superior da face; 4=movimento de nariz e terço superior da face e, classificaram a MF utilizando os critérios estabelecidos. Concordância intra e interavaliadores foram calculadas pelo coeficiente Kappa ponderado. A correlação entre os resultados das etapas com o FVF foi feita pelo coeficiente de correlação de Spearman. RESULTADOS: Na primeira etapa, a concordância interavaliadores variou de regular a substancial e na segunda, de substancial a quase perfeita. A concordância intra-avaliadores variou de moderada a quase perfeita na primeira etapa, e de moderada a substancial, na segunda etapa. A correlação entre a MF e área velofaríngea na primeira e na segunda etapa foi positiva e significativa. CONCLUSÃO: A proposta de julgamento da MF mostrou-se efetiva na determinação do sintoma e confiável no diagnóstico da gravidade da disfunção velofaríngea. A correlação significativa entre os métodos perceptivo e instrumental sugere que a MF pode ser utilizada na previsão do FVF.

Mímica facial durante a fala em fissura labiopalatina: uma proposta de classificação / Facial grimace during speech in cleft lip and palate: a proposal for classification

RESUMO Objetivo Investigar a efetividade de proposta de classificação da mímica facial (MF), e sua correlação com avaliação objetiva do fechamento velofaríngeo (FVF). Método Vinte indivíduos com fissura labiopalatina reparada foram submetidos à medida da área velofaríngea por meio da rinomanometria e à gravação de amostra de fala. A MF foi classificada em dois momentos, por três fonoaudiólogas. Inicialmente as avaliadoras classificaram a MF, utilizando critérios próprios, em: 1=MF ausente; 2=leve; 3=moderada; 4=grave. Posteriormente, foram submetidas a um treinamento com o estabelecimento dos seguintes critérios de classificação: 1=MF normal; 2=movimento somente de nariz ou terço superior da face; 3=movimento acentuado de nariz ou terço superior da face; 4=movimento de nariz e terço superior da face e, classificaram a MF utilizando os critérios estabelecidos. Concordância intra e interavaliadores foram calculadas pelo coeficiente Kappa ponderado. A correlação entre os resultados das etapas com o FVF foi feita pelo coeficiente de correlação de Spearman. Resultados Na primeira etapa, a concordância interavaliadores variou de regular a substancial e na segunda, de substancial a quase perfeita. A concordância intra-avaliadores variou de moderada a quase perfeita na primeira etapa, e de moderada a substancial, na segunda etapa. A correlação entre a MF e área velofaríngea na primeira e na segunda etapa foi positiva e significativa. Conclusão A proposta de julgamento da MF mostrou-se efetiva na determinação do sintoma e confiável no diagnóstico da gravidade da disfunção velofaríngea. A correlação significativa entre os métodos perceptivo e instrumental sugere que a MF pode ser utilizada na previsão do FVF.

ABSTRACT Purpose To investigate the effectiveness of a proposal for classification of facial grimace (FG) and its correlation with objective evaluation of velopharyngeal closure (VPC). Methods Twenty individuals with repaired cleft lip and palate underwent velopharyngeal area measurement by means of rhinomanometry and speech sample recording. The FG was rated in two steps, by three speech-language pathologists. First the evaluators rated the FG using their own criteria as: 1= absent FG; 2=mild; 3=moderate; 4=severe. Subsequently, they were submitted to a training session that established the following FG rating criteria: 1=absent FG; 2=movement only of the nose or upper third of the face; 3=strong movement of the nose or upper third of the face; 4=movement of the nose and upper third of the face. The evaluators rated the FG using the established criteria. Intra- and inter-rater agreement were calculated using weighted Kappa coefficient. Correlation between the two stage ratings with the VPC was calculated by Spearman's correlation coefficient. Results In the first stage inter-rater agreement ranged from fair to substantial; in the second stage, from substantial to almost perfect. Intra-rater agreement ranged from moderate to almost perfect in the first stage, and from moderate to substantial in the second stage. The correlation between FG and velopharyngeal area was positive and significant in both stages. Conclusion The proposed FG judgement proved to be effective in determining the symptom and reliable in diagnosing the severity of velopharyngeal dysfunction. The significant correlation between perceptual and instrumental methods suggests that FG can be used in predicting VPC.

Evaluation of the Nasopharyngeal Cannula Use After Orthognathic Surgery: Permeability of the Nasal Airways and Discomfort of the Patient With Cleft Lip and Palate.

It is believed that the use of the nasopharyngeal cannula can maintain the patent upper airway in the immediate post-operative period of orthognathic surgery. The present study is a randomized clinical trial with the objective of evaluating the difference in the use of the nasopharyngeal cannula in the post-operative period of orthognathic surgery with respect to permeability and discomfort. The sample was composed of 26 individuals with repaired cleft lip and palate randomly distributed in 2 groups with and without nasopharyngeal cannula. The evaluation was composed by Visual Analogue Scale (VAS), test with Altman mirror in 4 pre-operative periods, 6, 24, 30 hours after the operation. Rhinomanometry was also performed, a flow- pressure technique in 2 distinct moments, 6 and 24 hours after surgery. As a result, greater discomfort, greater obstruction as well as a reduction in the area of bilateral minimum nasal cross-section (ASTM) and increased resistance in the group with nasopharyngeal cannula are observed. In the intra-group comparison with the lowest ASTM values, the test group showed a significant difference between the first and the second moments (P = 0.001). It can be concluded that the nasopharyngeal cannula contributes to increase discomfort, worsens airway permeability by decreasing ASTM and increasing nasal resistance. Regarding the length of stay of the nasopharyngeal cannula, it can be said that from 6 hours onwards it does not contribute to the reduction of discomfort, airway permeability and assist in hemostasis.

Surgical maxillary advancement and speech resonance: comparison among cleft types. / Avanço cirúrgico de maxila e ressonância de fala: comparação entre os tipos de fissura.

Purpose This study investigated the influence of the cleft type on the appearance of hypernasality after surgical maxillary advancement (MA). Methods Nasality was determined by measurement of nasalance (acoustic correlate of nasality) by nasometry. The study involved analysis of the nasalance scores of 17 individuals with isolated cleft palate (CP), 118 with unilateral cleft lip and palate (UCLP) and 69 with bilateral cleft lip and palate (BCLP), of both sexes, aged 18 to 28 years, after MA. Only individuals with normal nasalance scores indicating balanced resonance before MA were included in this study. Nasometry was performed 3 days before and 15 months after MA, on average. The proportion of patients who presented nasalance scores indicating hypernasality after surgery was calculated by the ANOVA test, and comparison among the different cleft types was evaluated by the chi-square test (p < 0.05). Results No significant difference was found in the proportions of individuals with hypernasality among the cleft types. Conclusion Nasometry showed that the appearance of hypernasality after MA in individuals with cleft palate with or without cleft lip occurred in similar proportions, regardless of the cleft type.

Borg scale: a new method for hypernasality rating. / Escala de Borg: um novo método para avaliação da hipernasalidade de fala.

PURPOSE: To investigate the reliability in auditory-perceptual assessment of hypernasality of the Borg centiMax scale and the influence of the speech material on the reliability of two scales. METHODS: Four experienced speech-language pathologists rated hypernasality of 80 audio recordings of patients with repaired cleft palate (40 single-word string and 40 sentences) using the 5-point ordinal scale and the Borg centiMax scale. Intra and inter-rater reliability were calculated for both scales and for both types of speech samples. The comparison between the agreement coefficients of the two speech samples was calculated using the Z test and between the scales was calculated by Spearman correlation coefficient, considering as significant p<0.05. RESULTS: A very high and statistically significant correlation was found between the Borg centiMax scale and the ordinal scale for both speech samples. Intra- and inter-rater reliability was higher for Borg scale as compared to ordinal scale. Good to excellent intra-rater reliability was found for Borg scale for both speech samples. Poor to excellent intra-rater reliability was found for ordinal scale for both stimuli. Higher inter-rater reliability was demonstrated for Borg scale than ordinal scale for both speech samples. There was a significant difference between the single words string and sentences for intra- and inter-rater reliability using Borg scale, and for inter-rater reliability using ordinal scale. CONCLUSION: The Borg centiMax scale showed better intra and inter-rater reliability. Additionally, the speech material comprising of single words string showed better reliability in most of the comparisons for both scales.

OBJETIVO: Investigar a confiabilidade da escala Borg centiMax como método de avaliação perceptivo-auditiva da hipernasalidade e a influência do tipo de amostra de fala sobre a confiabilidade das avaliações. MÉTODO: Quatro fonoaudiólogas experientes classificaram a hipernasalidade de 80 amostras de fala de pacientes com fissura de palato reparada (40 vocábulos e 40 sentenças) utilizando a escala ordinal de 5 pontos e a escala Borg centiMax. Os índices de concordância intra e interavaliadores foram estabelecidos para ambas as escalas e amostras. A comparação desses índices foi feita pelo teste Z e a comparação entre as escalas foi feita pelo coeficiente de correlação de Spearman (p<0,05). RESULTADOS: Verificou-se correlação muito alta e significante entre a Escala Borg centiMax e a escala ordinal, para ambas as amostras. Os índices de concordância intra-avaliadores (CCI) para a escala Borg centiMax variaram de excelente a bom e, para a escala ordinal (Kappa), de excelente a pobre, em ambas as amostras. A concordância interavaliadores (CCI) para a escala Borg centiMax variou de excelente a moderada e, para a escala ordinal (Kappa), variou de moderada a pobre, para vocábulos e sentenças. Diferença estatisticamente significante, com melhores índices de concordância intra e interavaliadores para vocábulos, foi obtida com a escala Borg centiMax. Para a escala ordinal, diferença significante entre vocábulos e sentenças foi observada apenas para a comparação interavaliador. CONCLUSÃO: A escala Borg centiMax apresentou melhores índices de concordância intra e interavaliadores. A amostra contendo vocábulos mostrou melhores índices de concordância na maioria das comparações, para ambas as escalas.

Predictors of Velopharyngeal Dysfunction in Individuals With Cleft Palate Following Surgical Maxillary Advancement: Clinical and Tomographic Assessments.

OBJECTIVE: To investigate whether morphofunctional velopharyngeal aspects may be considered predictors of appearance or worsening of hypernasality in patients with cleft palate after surgical maxillary advancement (MA). DESIGN: Prospective. SETTING: National referral center for cleft lip and palate rehabilitation. PARTICIPANTS: Fifty-two patients with repaired cleft palate, skeletal class III malocclusion, and normal speech resonance completed speech audio recordings and cone-beam computed tomography examination before (T1) and, on average, 14 months after (T2) MA. INTERVENTIONS: Hypernasality was rated by 3 experienced speech-language pathologists using a 4-point scale and morphofunctional aspects on a 3-point scale. Cone-beam computed tomography image measurements were performed using Amira and Dolphin 3D software. For each velopharyngeal morphofunctional aspect analyzed, patients were compared according to the absence (G1) and presence (G2) of postoperative hypernasality. MAIN OUTCOME MEASURES: Comparison of hypernasality scores between T1 and T2 and association between hypernasality and each velopharyngeal morphofunctional aspect. RESULTS: Significant difference was observed between T1 and T2 for hypernasality ( P = .031) and between G1 and G2 ( P = .015) for velar mobility, with significant association between this variable and hypernasality on T2 (P = .041). CONCLUSIONS: Levator veli palatini mobility influenced the appearance of hypernasality after MA.

Normative nasalance scores in the production of words and syllables for Brazilian Portuguese speakers.

The objective of this study was to determine normative nasalance scores for non-cleft children, adolescents and adults, native speakers of Brazilian Portuguese, during the production of words and syllables, for cross-linguistic comparisons in populations with and without cleft palate. Nasalance was assessed in 62 individuals, aged 6-10 years (n = 20), 11-17 years (n = 20) and 18-35 years (n = 22), using a nasometer II model 6450 (KayPENTAX), during production of one sequence of nine oral words (pipa, bis, burro, tatu, pilha, cuca, gui, fila, luz) and of sequences of isolated syllables (e.g. pa, pa, pa, pa, pa, pa) composed of plosive, fricative, liquid and nasal consonants with high and low vowels. In order to validate the new nasalance stimuli, nasalance scores for traditional oral and nasal stimuli were also obtained. Differences were analyzed at a significance level of 0.01. Mean nasalance scores (±SD) during the production of the sequence of words were 18 ± 5% (children), 18 ± 7% (adolescents) and 21 ± 5% (adults). Differences between age groups were not significant. During the production of syllables, adults had the highest mean nasalance scores (except for syllable /mi/); significant differences between age groups were observed only for /pa/ ,/sa/ and /la/. Nasalance scores were significantly higher in oral and nasal syllables with high vowels than with low vowels, and in nasal syllables than in oral syllables with high and low vowels. The nasalance scores obtained for the sentences were comparable to previously established norms. In conclusion, the nasalance scores defined for Brazilian Portuguese speakers, in different stimuli, may be adopted as normative values for local and cross-language comparisons in the identification of hypernasality related to conditions such as cleft palate, neurogenic disorders and syndromes.

A secção cirúrgica do retalho faríngeo pode comprometer a ressonância de fala de indivíduos com fissura labiopalatina? / Could the speech resonance of individuals with cleft lip and palate be affected by complete section of pharyngeal flap?

RESUMO Objetivo Investigar o efeito da cirurgia para secção completa do retalho faríngeo sobre a hipernasalidade de fala. Métodos Foram avaliados 26 indivíduos com fissura de palato±lábio reparada, submetidos à cirurgia de retalho faríngeo para tratamento da insuficiência velofaríngea e que, em função do aparecimento de queixas respiratórias, necessitaram nova cirurgia para secção do retalho. A hipernasalidade foi determinada por meio das avaliações perceptiva e nasométrica da fala 18 meses, em média, após a secção do retalho. Na avaliação perceptiva, a hipernasalidade foi classificada como: 1 = ausente ou 2 = presente e, na nasometria, foi determinada por meio da medida da nasalância durante a leitura de sentenças contendo, exclusivamente, sons orais, considerando-se, como limite de normalidade, o escore de 27% (p ≤ 0,05). Resultados A avaliação perceptiva mostrou que, antes da secção do retalho, oito (31%) indivíduos apresentavam ressonância equilibrada e 18 (69%) apresentavam hipernasalidade. Após a cirurgia, um (4%) paciente permaneceu com ressonância equilibrada e 25 (96%) apresentaram hipernasalidade. De acordo com a nasometria, antes da cirurgia, 13 (57%) indivíduos apresentaram valores de nasalância inferiores a 27%, indicando ausência de hipernasalidade (média = 15±8%) e dez (43%) pacientes apresentaram valores indicativos de hipernasalidade (média = 41±7%). Após a cirurgia, quatro (17%) pacientes permaneceram com valores indicativos de ausência de hipernasalidade (média = 19±10%) e 19 (83%) apresentaram valores de nasalância indicativos de hipernasalidade (média = 45±7%). Diferença entre as avaliações perceptiva e nasométrica da fala não foi observada. Conclusão A cirurgia para secção completa do retalho faríngeo causou deterioração da ressonância de fala, levando ao reaparecimento da hipernasalidade, na maioria dos pacientes estudados.

ABSTRACT Purpose To investigate the effect of complete section of pharyngeal flap on speech hypernasality. Methods The study analyzed twenty-six individuals with repaired cleft palate±lip underwent pharyngeal flap surgery to treat velopharyngeal insufficiency and posteriorly underwent complete section of the flap due to the occurrence of respiratory symptoms. Hypernasality was determined by auditory-perceptual speech assessments and nasometry at 18 months after surgery, on average. Hypernasality was perceptually classified as: 1 = absent or 2 = present and determined by nasalance measurement during reading of sentences containing exclusively oral sounds, considering a cutoff of 27% (p ≤ 0.05). Results Perceptual assessment before section of the flap revealed that eight (31%) individuals showed normal resonance, while 18 (69%) presented hypernasality. After surgery, one (4%) subject remained with normal resonance and 25 (96%) presented hypernasality. According to nasometry, before surgery, 13 (57%) individuals presented nasalance scores lower than 27%, indicative of absence of hypernasality (mean = 15±8%) and ten (43%) presented nasalance scores indicative of hypernasality (mean = 41±7%). After surgery, four (17%) patients remained with scores indicative of absence of hypernasality (mean = 19±10%) and for 19 (83%) the nasalance scores were indicative of hypernasality (mean = 45±7%). There was no difference between perceptual and nasometric speech evaluations. Conclusion Surgery for complete section of pharyngeal flap caused deterioration of speech resonance, leading to the reappearance of hypernasality in most patients in this study.

Reliability of Hypernasality Rating: Comparison of 3 Different Methods for Perceptual Assessment.

OBJECTIVE: To compare reliability in auditory-perceptual assessment of hypernasality for 3 different methods and to explore the influence of language background. DESIGN: Comparative methodological study. PARTICIPANTS AND MATERIALS: Audio recordings of 5-year-old Swedish-speaking children with repaired cleft lip and palate consisting of 73 stimuli of 9 nonnasal single-word strings in 3 different randomized orders. Four experienced speech-language pathologists (2 native speakers of Brazilian-Portuguese and 2 native speakers of Swedish) participated as listeners. After individual training, each listener performed the hypernasality rating task. Each order of stimuli was analyzed individually using the 2-step, VISOR and Borg centiMax scale methods. MAIN OUTCOME MEASURES: Comparison of intra- and inter-rater reliability, and consistency  for each method within language of the listener and between listener languages (Swedish and Brazilian-Portuguese). RESULTS: Good to excellent intra-rater reliability was found within each listener for all methods, 2-step: κ = 0.59-0.93; VISOR: intraclass correlation coefficient (ICC) = 0.80-0.99; Borg centiMax (cM) scale: ICC = 0.80-1.00. The highest inter-rater reliability was demonstrated for VISOR (ICC = 0.60-0.90) and Borg cM-scale (ICC = 0.40-0.80). High consistency within each method was found with the highest for the Borg cM scale (ICC = 0.89-0.91). There was a significant difference in the ratings between the Swedish and the Brazilian listeners for all methods. CONCLUSIONS: The category-ratio scale Borg cM was considered most reliable in the assessment of hypernasality. Language background of Brazilian-Portuguese listeners influenced the perceptual ratings of hypernasality in Swedish speech samples, despite their experience in perceptual assessment of cleft palate speech disorders.

Nasalance scores of Brazilian Portuguese speakers at 5 years of age. / Escores de nasalância de falantes do Português Brasileiro aos cinco anos de idade.

PURPOSE: To determine nasalance scores of Brazilian Portuguese speaking children without evident speech disorders, language delay and orofacial deformities, at age 5 years, and analyze differences between types of speech samples and genders. METHODS: Twenty children were analyzed, 11 males, age ranging from 4 years and 10 months to 5 years and 11 months. The Nasometer II 6450 (KayPENTAX) was used for nasalance assessment. Speech samples were eight consonant-vowel syllables and one sequence of nine words. The significance of differences between speech samples and genders were assessed by the Tukey test and Mann-Whitney test, respectively, at a significance level of 5%. RESULTS: Mean nasalance scores were: /pa/= 10±4%, /pi/= 22±7%, /sa/= 11±5%, /si/= 24±11%, /ma/= 57±11%, /mi/= 73±13%, /la/= 14±9%, /li/= 25±11%, words (pipa, bis, burro, tatu, pilha, cuca, gui, fila, luz)= 20±6%. Nasalance scores of nasal syllables were significantly higher than those of oral syllables (with high or neutral vowels) and nasalance scores of oral syllables with high vowels were significantly higher than those of oral syllables with neutral vowels, for the majority of comparisons. There was no difference between genders. CONCLUSION: Normative nasalance scores for 5-year-old Brazilian children were determined. The methodology can serve as a standard for the early diagnosis of nasality deviations, such as hypernasality observed in cleft palate speech.

Escores de nasalância de falantes do Português Brasileiro aos cinco anos de idade / Nasalance scores of Brazilian Portuguese speakers at 5 years of age

RESUMO Objetivo Determinar valores de nasalância de crianças falantes do Português Brasileiro sem alterações na produção da fala, atraso de linguagem e deformidades dentofaciais evidentes, aos 5 anos de idade, e verificar as diferenças entre tipos de emissão e entre gêneros. Método A nasalância foi determinada em 20 crianças, 11 do gênero masculino e idade entre 4 anos e 10 meses e 5 anos e 11 meses, utilizando um nasômetro II 6450 (KayPENTAX), na produção de oito sílabas tipo consoante-vogal e uma sequência de nove vocábulos. A significância das diferenças entre os tipos de emissões foi verificada pelo Teste de Tukey e, entre os gêneros, pelo teste de Mann-Whitney, para um nível de 5%. Resultados Os valores médios de nasalância foram os seguintes: /pa/= 10±4%, /pi/= 22±7%, /sa/= 11±5%, /si/= 24±11%, /ma/= 57±11%, /mi/= 73±13%, /la/= 14±9%, /li/= 25±11%, vocábulos (pipa, bis, burro, tatu, pilha, cuca, gui, fila, luz)= 20±6%. Na maioria das comparações, os valores de nasalância das sílabas nasais foram significantemente maiores do que os das sílabas orais (com vogal alta ou neutra) e os valores das sílabas orais com vogal alta foram significativamente maiores que os das sílabas orais com vogal neutra. Não houve diferença significante entre os gêneros. Conclusão Foram definidos valores normais de nasalância de crianças falantes do Português Brasileiro, de 5 anos de idade, sendo que a metodologia empregada pode servir de padrão para o diagnóstico precoce de desvios de nasalidade, como a hipernasalidade observada na fala de crianças com fissura palatina.

ABSTRACT Purpose To determine nasalance scores of Brazilian Portuguese speaking children without evident speech disorders, language delay and orofacial deformities, at age 5 years, and analyze differences between types of speech samples and genders. Methods Twenty children were analyzed, 11 males, age ranging from 4 years and 10 months to 5 years and 11 months. The Nasometer II 6450 (KayPENTAX) was used for nasalance assessment. Speech samples were eight consonant-vowel syllables and one sequence of nine words. The significance of differences between speech samples and genders were assessed by the Tukey test and Mann-Whitney test, respectively, at a significance level of 5%. Results Mean nasalance scores were: /pa/= 10±4%, /pi/= 22±7%, /sa/= 11±5%, /si/= 24±11%, /ma/= 57±11%, /mi/= 73±13%, /la/= 14±9%, /li/= 25±11%, words (pipa, bis, burro, tatu, pilha, cuca, gui, fila, luz)= 20±6%. Nasalance scores of nasal syllables were significantly higher than those of oral syllables (with high or neutral vowels) and nasalance scores of oral syllables with high vowels were significantly higher than those of oral syllables with neutral vowels, for the majority of comparisons. There was no difference between genders. Conclusion Normative nasalance scores for 5-year-old Brazilian children were determined. The methodology can serve as a standard for the early diagnosis of nasality deviations, such as hypernasality observed in cleft palate speech.

Influência das consoantes de alta e baixa pressão intraoral sobre a nasalidade e nasalância da fala em pacientes com fissura de palato reparada / Influence of high and low intraoral pressure consonants on the speech nasality and nasalance in patients with repaired cleft palate

RESUMO Introdução Na fissura de palato, a realização de um diagnóstico preciso das alterações de fala auxilia o processo de reabilitação, direcionando o tratamento para a disfunção velofaríngea. Objetivo Determinar o estímulo de fala que melhor identifica a hipernasalidade, comparando a nasalidade da fala e a nasalância em estímulos de alta e baixa pressão intraoral, em indivíduos com fissura palatina. Métodos Quarenta e quatro indivíduos com fissura de palato±lábio operada, de ambos os sexos, com idades entre 6 e 59 anos, foram submetidos, simultaneamente, à nasometria e gravação de fala. A nasalância foi determinada utilizando amostras de fala com consoantes de alta pressão intraoral (AP) e consoantes de baixa pressão intraoral (BP). Três examinadores experientes classificaram a nasalidade nas duas amostras (AP e BP), de acordo com uma escala de 4 pontos (1=hipernasalidade ausente, 2=hipernasalidade leve, 3=hipernasalidade moderada, 4=hipernasalidade grave). Resultados Os escores médios ±desvio padrão de nasalância obtidos para as amostras AP e BP foram 31±15% e 31±12%, respectivamente, sem diferença (p=1,0). A concordância entre os examinadores foi maior para as amostras AP. A média de nasalidade entre as duas amostras apresentou diferença (p=0,05). As amostras AP apresentaram forte correlação entre os escores de nasalância e hipernasalidade e as amostras BP apresentaram correlação substancial. Conclusão A amostra composta por consoantes de alta pressão intraoral mostrou maior eficácia na identificação da hipernasalidade, pois proporcionou maior concordância entre os examinadores na análise perceptual da nasalidade, apresentou forte correlação entre os dois métodos utilizados e permitiu o diagnóstico de hipernasalidade em maior número de indivíduos.

ABSTRACT Introduction In the cleft palate, the accurate diagnosis of speech disorders helps the rehabilitation process by directing the treatment of velopharyngeal dysfunction. Purpose To verify the influence of pressure consonants on speech nasality and nasalance, comparing high and low intraoral pressure stimuli in individuals with cleft palate. Methods Forty-four subjects with repaired cleft palate±lip, both genders, aged 6 to 59 years were simultaneously submitted to nasometry and audio speech sample recording. Nasalance scores were determined for speech samples with high-pressure consonants (HP) and low-pressure consonants (LP). Three experienced raters classified speech nasality in both samples (HP and LP) according to a 4-point scale (1 = absent hypernasality, 2 = mild hypernasality, 3 = moderate hypernasality, 4 = severe hypernasality). Results Nasalance scores±SD obtained for HP and LP samples were 31±15% and 31±12%, respectively, with no difference (p=1.0). The inter-rater agreement was higher for HP sample. The average rate of nasality between both samples showed difference (p=0.05). HP samples presented strong correlation between nasalance scores and hypernasality and LP samples presented substantial correlation. Conclusion The HP speech sample was shown to be more effective in identifying hypernasality, as it provided greater agreement among examiners in the perceived nasality analysis, had a strong correlation between the two methods used and allowed diagnosis of velopharyngeal disfunction in a larger number of individuals.

Comparação entre duas abordagens diferentes de tratamento cirúrgico da insuficiência velofaríngea / Comparison between two different approaches of surgical management for velopharyngeal insufficiency

RESUMO Introdução A palatoplastia secundária com veloplastia intravelar (VI) pode ser realizada previamente ao retalho faríngeo (RF), para o tratamento cirúrgico da insuficiência velofaríngea em pacientes com fissura palatina. Esta abordagem cirúrgica tem como finalidade melhorar as condições velofaríngeas, evitando, assim, a indicação de um retalho faríngeo largo e seus efeitos indesejáveis sobre a respiração. Objetivo Investigar os efeitos do retalho faríngeo realizado após a veloplastia intravelar para tratamento da insuficiência velofaríngea sobre a nasalidade e a respiração. Métodos Análise dos resultados pós-cirúrgicos da nasalidade de fala e da respiração de 50 indivíduos com fissura de palato reparada e insuficiência velofaríngea, sendo 23 submetidos ao retalho faríngeo após a veloplastia intravelar (Grupo VI+RF) e 27 submetidos unicamente ao retalho faríngeo (Grupo RF). A nasalidade foi determinada pela nasometria e o efeito da cirurgia sobre a respiração foi analisado pela medida da área de secção transversa mínima nasofaríngea, obtida pela técnica fluxo-pressão e pelo levantamento das queixas respiratórias, utilizando questionário específico. A comparação estatística entre os grupos foi realizada por meio do teste Mann-Whitney e teste t de Student, considerando significante o valor de p<0,05. Resultados Verificou-se que não houve diferença entre os grupos para os resultados de nasalidade, da medida da área nasofaríngea e do levantamento de queixas respiratórias. Conclusão Ambas as abordagens para tratamento cirúrgico da insuficiência velofaríngea mostraram resultados equivalentes, no que se refere à eliminação da hipernasalidade, bem como à condição da respiração, sugerindo que a realização do retalho faríngeo após a veloplastia intravelar não levou a melhores resultados de ressonância de fala e não favoreceu a respiração.

ABSTRACT Introduction Secondary palatoplasty with intravelar veloplasty (IV) may be performed before pharyngeal flap (PF) for surgical treatment of velopharyngeal insufficiency in individuals with cleft palate. This surgical approach aims to improve the velopharyngeal conditions, thus avoiding indication of a large pharyngeal flap and its undesirable effects on respiration. Purpose To investigate the effects of pharyngeal flap performed after intravelar veloplasty for the treatment of velopharyngeal insufficiency on nasality and respiration. Methods Analysis of postoperative outcomes of speech nasality and respiration in 50 individuals with repaired cleft palate and velopharyngeal insufficiency, being 23 submitted to pharyngeal flap after intravelar veloplasty (Group IV+PF) and 27 submitted only to pharyngeal flap (Group PF). Nasality was determined by nasometry, and the effect of surgery on respiration was assessed by measuring the minimum nasopharyngeal transverse section area, obtained by the pressure-flow technique and investigation of respiratory complaints, using a specific questionnaire. Statistical comparison between groups was performed by the Mann-Whitney test and Student t test, at a significance level of p<0.05. Results There was no difference between groups for the outcomes of nasality, measurement of nasopharyngeal area and investigation of respiratory complaints. Conclusion Both approaches for surgical treatment of velopharyngeal insufficiency demonstrated similar outcomes concerning the elimination of hypernasality, as well as for respiration, suggesting that accomplishment of pharyngeal flap after intravelar veloplasty did not provide better speech resonance outcomes nor favored respiration.

Nasopharyngeal dimensions in normal individuals: normative data. / Dimensões nasofaríngeas em indivíduos sem anomalias craniofaciais: dados normativos.

OBJECTIVE: To establish normative values of minimum cross-sectional nasopharyngeal area in individuals without craniofacial anomalies at different age ranges. MATERIAL AND METHOD: Ninety-six individuals of both genders, without craniofacial anomalies, and with normal body mass index and neck circumference were evaluated. Participants were divided into 4 age groups: children, aged 6 to 10 years (G1); adolescents, aged 11 to 17 years (G2); young adults, 18 to 39 years (G3), and middle-aged adults, 40 to 59 years (G4). Minimum cross-sectional nasopharyngeal area (nasopharyngeal area - NPA) was assessed by means of modified anterior rhinomanometry (pressure-flow technique) using a PERCI-SARS system (version 3.50 - Microtronics Corp.). RESULTS: Mean±SD values of NPA were 1.025±0.054cm2, 1.055±0.081cm2, 1.050±0.083cm2, and 1.054±0.081cm2, respectively for groups G1, G2, G3, and G4, showing that there were no differences between the four age groups. CONCLUSION: Normative data of NPA were established for individuals without craniofacial anomalies from different age ranges, and they may be used as reference values in the clinical routine and for future studies regarding nasopharyngeal obstruction diagnosis, particularly in cases of craniofacial anomalies.

Dimensões nasofaríngeas em indivíduos sem anomalias craniofaciais: dados normativos / Nasopharyngeal dimensions in normal individuals: normative data

RESUMO Objetivo Determinar os valores controles da área de secção transversa mínima nasofaríngea de indivíduos sem anomalias craniofaciais e em diferentes faixas etárias. Material e Método Participaram do estudo 96 indivíduos sem anomalias craniofaciais, de ambos os sexos, com índice de massa corpórea e circunferência cervical normais, subdivididos em 4 grupos etários: crianças com idade entre 6 e 10 anos (G1), adolescentes de 11 a 17 anos (G2), adultos jovens entre 18 e 39 anos (G3) e adultos de meia-idade entre 40 e 59 anos (G4). A área seccional transversa mínima nasofaríngea (área nasofaríngea – ANF) foi determinada por meio de rinomanometria anterior modificada (técnica fluxo-pressão), utilizando o sistema PERCI-SARS (versão 3.50 – Microtronics Corp.). Resultados Os valores médios±DP da ANF foram de 1,025±0,054cm2, 1,055±0,081cm2, 1,050±0,083cm2 e 1,054±0,081cm2, respectivamente, para G1, G2, G3 e G4, não havendo diferença entre as 4 faixas etárias. Conclusão Os valores controles da ANF foram determinados para indivíduos sem anomalias craniofaciais de diferentes faixas etárias e servirão de referência na rotina clínica e em estudos envolvendo diagnóstico de obstrução nasofaríngea, principalmente na presença de anomalias craniofaciais.

ABSTRACT Objective To establish normative values of minimum cross-sectional nasopharyngeal area in individuals without craniofacial anomalies at different age ranges. Material and Method Ninety-six individuals of both genders, without craniofacial anomalies, and with normal body mass index and neck circumference were evaluated. Participants were divided into 4 age groups: children, aged 6 to 10 years (G1); adolescents, aged 11 to 17 years (G2); young adults, 18 to 39 years (G3), and middle-aged adults, 40 to 59 years (G4). Minimum cross-sectional nasopharyngeal area (nasopharyngeal area – NPA) was assessed by means of modified anterior rhinomanometry (pressure-flow technique) using a PERCI-SARS system (version 3.50 – Microtronics Corp.). Results Mean±SD values of NPA were 1.025±0.054cm2, 1.055±0.081cm2, 1.050±0.083cm2, and 1.054±0.081cm2, respectively for groups G1, G2, G3, and G4, showing that there were no differences between the four age groups. Conclusion Normative data of NPA were established for individuals without craniofacial anomalies from different age ranges, and they may be used as reference values in the clinical routine and for future studies regarding nasopharyngeal obstruction diagnosis, particularly in cases of craniofacial anomalies.

Influence of speech sample on perceptual rating of hypernasality. / Influência da amostra de fala na classificação perceptiva da hipernasalidade.

PURPOSE: To investigate the influence of speech sample of spontaneous conversation or sentences repetition on intra and inter-rater hypernasality reliability. METHODS: One hundred and twenty audio recorded speech samples (60 containing spontaneous conversation and 60 containing repeated sentences) of individuals with repaired cleft palate±lip, both genders, aged between 6 and 52 years old (mean=21±10) were selected and edited. Three experienced speech and language pathologists rated hypernasality according to their own criteria using 4-point scale: 1=absence of hypernasality, 2=mild hypernasality, 3=moderate hypernasality and 4=severe hypernasality, first in spontaneous speech samples and 30 days after, in sentences repetition samples. Intra- and inter-rater agreements were calculated for both speech samples and were statistically compared by the Z test at a significance level of 5%. RESULTS: Comparison of intra-rater agreements between both speech samples showed an increase of the coefficients obtained in the analysis of sentences repetition compared to those obtained in spontaneous conversation. Comparison between inter-rater agreement showed no significant difference among the three raters for the two speech samples. CONCLUSION: Sentences repetition improved intra-raters reliability of perceptual judgment of hypernasality. However, the speech sample had no influence on reliability among different raters.

Influência da amostra de fala na classificação perceptiva da hipernasalidade / Influence of speech sample on perceptual rating of hypernasality

RESUMO Objetivo Investigar a influência do tipo de amostra de fala, conversa espontânea ou repetição de sentenças, sobre o índice de concordância intra e interavaliadores obtido na classificação perceptiva da hipernasalidade. Métodos Foram selecionadas e editadas 120 amostras de fala gravadas em áudio (60 contendo trechos de conversa espontânea e 60 contendo repetição de sentenças) de indivíduos com fissura de palato±lábio reparada, de ambos os sexos, com idade entre 6 e 52 anos (média=21±10 anos). Três fonoaudiólogas experientes, utilizando seus critérios internos, classificaram a hipernasalidade em escala de 4 pontos: 1=ausente, 2=leve, 3=moderada e 4=grave, primeiramente na amostra de conversa espontânea e, 30 dias depois, na repetição de sentenças. Os índices de concordância intra e interavaliadores foram estabelecidos para ambos os tipos de amostra de fala e comparados entre si por meio do Teste Z com nível de significância de 5%. Resultados A comparação dos índices de concordância intra-avaliadores entre os dois tipos de amostra de fala mostrou aumento dos coeficientes obtidos na análise da repetição de sentenças em relação aos obtidos na conversa espontânea, já a comparação entre os índices de concordância interavaliadores não mostrou diferença significante entre as três avaliadoras para os dois tipos de amostras de fala. Conclusão A repetição de sentenças favoreceu a confiabilidade do julgamento perceptivo da hipernasalidade de um mesmo avaliador, visto que a concordância intra-avaliadores na análise desta amostra de fala foi maior. No entanto, o tipo de amostra de fala não influenciou a concordância entre diferentes avaliadores.

ABSTRACT Purpose To investigate the influence of speech sample of spontaneous conversation or sentences repetition on intra and inter-rater hypernasality reliability. Methods One hundred and twenty audio recorded speech samples (60 containing spontaneous conversation and 60 containing repeated sentences) of individuals with repaired cleft palate±lip, both genders, aged between 6 and 52 years old (mean=21±10) were selected and edited. Three experienced speech and language pathologists rated hypernasality according to their own criteria using 4-point scale: 1=absence of hypernasality, 2=mild hypernasality, 3=moderate hypernasality and 4=severe hypernasality, first in spontaneous speech samples and 30 days after, in sentences repetition samples. Intra- and inter-rater agreements were calculated for both speech samples and were statistically compared by the Z test at a significance level of 5%. Results Comparison of intra-rater agreements between both speech samples showed an increase of the coefficients obtained in the analysis of sentences repetition compared to those obtained in spontaneous conversation. Comparison between inter-rater agreement showed no significant difference among the three raters for the two speech samples. Conclusion Sentences repetition improved intra-raters reliability of perceptual judgment of hypernasality. However, the speech sample had no influence on reliability among different raters.