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

BACKGROUND: Differing results regarding articulation skills in young children with cleft palate (CP) have been reported and often interpreted as a consequence of different surgical protocols. AIMS: To assess the influence of different timing of hard palate closure in a two-stage procedure on articulation skills in 3-year-olds born with unilateral cleft lip and palate (UCLP). Secondary aims were to compare results with peers without CP, and to investigate if there are gender differences in articulation skills. Furthermore, burden of treatment was to be estimated in terms of secondary surgery, hearing and speech therapy. METHODS & PROCEDURES: A randomized controlled trial (RCT). Early hard palate closure (EHPC) at 12 months versus late hard palate closure (LHPC) at 36 months in a two-stage procedure was tested in a cohort of 126 Danish-speaking children born with non-syndromic UCLP. All participants had the lip and soft palate closed around 4 months of age. Audio and video recordings of a naming test were available from 113 children (32 girls and 81 boys) and were transcribed phonetically. Recordings were obtained prior to hard palate closure in the LHPC group. The main outcome measures were percentage consonants correct adjusted (PCC-A) and consonant errors from blinded assessments. Results from 36 Danish-speaking children without CP obtained previously by Willadsen in 2012 were used for comparison. OUTCOMES & RESULTS: Children with EHPC produced significantly more target consonants correctly (83%) than children with LHPC (48%; p < .001). In addition, children with LHPC produced significantly more active cleft speech characteristics than children with EHPC (p < .001). Boys achieved significantly lower PCC-A scores than girls (p = .04) and produced significantly more consonant errors than girls (p = .02). No significant differences were found between groups regarding burden of treatment. The control group performed significantly better than the EHPC and LHPC groups on all compared variables.

[Improving the speech with a prosthetic construction]. / Een prothetische constructie ter verbetering van de spraak.

A 12-year-old boy had problems with his speech due to a defect in the soft palate. This defect was caused by the surgical removal of a synovial sarcoma. Testing with a nasometer revealed hypernasality above normal values. Given the size and severity of the defect in the soft palate, the possibility of improving the speech with speech therapy was limited. At a centre for special dentistry an attempt was made with a prosthetic construction to improve the performance of the palate and, in that way, the speech. This construction consisted of a denture with an obturator attached to it. With it, an effective closure of the palate could be achieved. New measurements with acoustic nasometry showed scores within the normal values. The nasality in the speech largely disappeared. The obturator is an effective and relatively easy solution for palatal insufficiency resulting from surgical resection. Intrusive reconstructive surgery can be avoided in this way.

Normative nasalance data in Ugandan english-speaking children.

AIMS: The aim of this study was to obtain normative nasalance values for typically developing Ugandan English-speaking children as a reference point for clinical practice and further research. METHODS: Sixty-nine typically developing Ugandan children (35 males and 34 females, 2.7-13.5 years of age) participated in the study. Nasalance scores were obtained with the Nasometer while children repeated 4 sustained sounds, 14 repeated syllables, 15 sentences (12 oral, 3 nasal) and 2 texts ('Rainbow Passage' and 'Zoo Passage'). Data were analyzed for gender and age dependence. RESULTS: No significant effects of age or gender on nasalance values were obtained; hence, normative values for the overall group were reported. The average nasalance scores for Ugandan English-speaking children were 17 and 64% for the oral and nasal sentences and 33 and 14% for the oronasal and oral text, respectively. CONCLUSION: The normative values are important as a reference point to assess the impact of several surgical procedures and several surgical timing strategies on speech in Uganda.

Impact of tongue reduction on overall speech intelligibility, articulation and oromyofunctional behavior in 4 children with Beckwith-Wiedemann syndrome.

OBJECTIVE: The purpose of this study was to determine the impact of partial glossectomy (using the keyhole technique) on speech intelligibility, articulation, resonance and oromyofunctional behavior. PATIENTS AND METHODS: A partial glossectomy was performed in 4 children with Beckwith- Wiedemann syndrome between the ages of 0.5 and 3.1 years. An ENT assessment, a phonetic inventory, a phonemic and phonological analysis and a consensus perceptual evaluation of speech intelligibility, resonance and oromyofunctional behavior were performed. RESULTS: It was not possible in this study to separate the effects of the surgery from the typical developmental progress of speech sound mastery. Improved speech intelligibility, a more complete phonetic inventory, an increase in phonological skills, normal resonance and increased motor-oriented oral behavior were found in the postsurgical condition. The presence of phonetic distortions, lip incompetence and interdental tongue position were still present in the postsurgical condition. CONCLUSION: Speech therapy should be focused on correct phonetic placement and a motor-oriented approach to increase lip competence, and on functional tongue exercises and tongue lifting during the production of alveolars. Detailed analyses in a larger number of subjects with and without Beckwith-Wiedemann syndrome may help further illustrate the long-term impact of partial glossectomy.

[Neonatal tongue-tie: myths and science].

Anatomical restraining of tongue movement (tongue-tie, ankyloglossia) has been known for centuries and the subject of dozens of articles. The heated debate persists on its clinical significance and indications for treatment. Most authorities in the field of infant feeding and Lactation agree that breastfeeding problems, such as nipple pain and latching difficulties, are common signs of clinicaLly significant tongue-tie and indications for performing a frenotomy, while the sole presence of a visible lingual frenulum is not. In contrast, the lack of a visible frenulum does not rule out the diagnosis of clinically significant tongue-tie since submucosal ties, also called "posterior tongue-tie", may interfere with efficient breastfeeding. Whether tongue-tie interferes with speech articulation to a significant extent is currently unknown. Theoretically, articulation of some consonants (e.g., /s/, /th/, /r/) would be affected by impeded tongue movement. These articulation problems are, however, Less common than tongue-tie itself, and children and adults characteristically use various compensatory techniques of mouth opening and tongue movements. When it is indicated, frenotomy is performed by lifting the tongue and snipping the frenulum with scissors. Complications of frenotomy are rare and consist mainly of self-limited minor bleeding. The significance of posterior tongue tie and the long-term effects of frenotomy performed during early infancy are unresolved issues.

Phonological development in children with obstructive sleep-disordered breathing.

Adeno-tonsillar hypertrophy with obstructive sleep disordered breathing (OSDB) is known to affect oral-motor function, behaviour, and academic performance. Adeno-tonsillectomy is the most frequently performed operation in children, with total tonsillectomy (TE) being more common than partial resection, 'tonsillotomy' (TT). In the present study 67 children, aged 50-65 months, with OSBD were randomized to TE or TT. The children's phonology was assessed pre-operatively and 6 months post-operatively. Two groups of children served as controls. Phonology was affected in 62.7% of OSBD children before surgery, compared to 34% in the control group (p < .001). Also, OSBD children had more severe phonological deficits than the controls (p < .001). Phonology improved 6 months equally after both surgeries. Despite improvement post-operatively, the gap to the controls increased. Other functional aspects, such as oral motor function, were normalized regardless of surgical method--TE or TT. The impact of OSBD should be considered as one contributing factor in phonological impairment.

The Pushback Pharyngeal Flap: An 18-Year Experience.

BACKGROUND: The pharyngeal flap is one of the oldest and most popular techniques for correction of velopharyngeal insufficiency. The authors describe a large series using a technique that combines a pharyngeal flap with a palate pushback to avoid common causes of operative failure while restoring the velopharyngeal mechanism. METHODS: A retrospective cohort study was performed of patients who underwent a pushback pharyngeal flap by a single surgeon from 2000 to 2017. All patients had a preoperative nasoendoscopy diagnostic of velopharyngeal insufficiency. Operative technique involved elevation of the hard palate mucosa through a retroalveolar incision, passage of the flap through the nasopharyngeal mucosa opening, and inset with sutures through the hard palate mucosa. RESULTS: There were 40 patients with a median age of 9.7 years. Preoperative closure patterns were predominately coronal (85.7 percent), with poor posterior wall motion and an average gap size of 27.5 mm. Postoperative complications included flap dehiscence (n = 1), transient dysphagia (n = 2), obstructive sleep apnea (n = 4), and a palatal fistula and/or persistent velopharyngeal insufficiency that required further surgery (n = 6). At an average of 2.5 years postoperatively, 91.7 percent of patients achieved adequate velopharyngeal function, with significant improvements in the majority of speech metrics (p < 0.001). CONCLUSIONS: The pushback pharyngeal flap is a safe and effective technique for treatment of velopharyngeal insufficiency. Advantages include high, secure inset with prevention of palatal scar contracture and shortening. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Interventions for the management of submucous cleft palate.

BACKGROUND: Submucous cleft palate (SMCP) is a common congenital malformation of the soft palate which may present as velopharyngeal insufficiency (VPI), which can affect the quality and intelligibility of speech. Surgical techniques, which can be used to reconstruct these structural or anatomical defects and to correct velopharyngeal insufficiency, include palatal repair and procedures that rearrange the muscle attachments of the soft palate. OBJECTIVES: To provide reliable evidence regarding the effectiveness of surgical interventions to treat velopharyngeal insufficiency and improve speech in patients with submucous cleft palate. SEARCH STRATEGY: We searched the Cochrane Oral Health Group Trials Register (to 21st December 2006); Cochrane Developmental, Psychosocial and Learning Problems Group Trials Register (on 12th March 2007); the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2006, Issue 4); MEDLINE (from 1966 to 21st December 2006); EMBASE (from 1980 to 21st December 2006); and CINAHL, ERIC, PsycINFO (on 7th March 2007). SELECTION CRITERIA: Randomised controlled trials comparing surgical interventions to correct velopharyngeal insufficiency in submucous cleft palate. DATA COLLECTION AND ANALYSIS: Limited data from one included trial precluded pooling of data, and only a descriptive summary is presented. MAIN RESULTS: This review included one trial, involving 72 participants aged 4 to 7 years with submucous cleft palate associated velopharyngeal insufficiency, which compared minimal incision palatopharyngoplasty (MIPP) to MIPP with additional velopharyngeal surgery, either pharyngeal flap (32) or sphincter pharyngoplasty (3). The trial provided no information about post-operative speech assessment, very limited data on any instrumental assessments and there were no reports of obstructive sleep apnoea or other adverse effects after the interventions. Complete closure occurred in 32 (86%) of the participants in the MIPP group and in 31 (89%) in the additional treatment group, P > 0.05. After eliminating the nine patients with residual velopharyngeal insufficiency, the post-operative gap size during closure was 7.4 +/-3.2% in the MIPP group and 8 +/-4.1% in the additional intervention group (P > 0.5). AUTHORS' CONCLUSIONS: The trial provided some weak and unreliable evidence that there was no significant difference in the effectiveness of minimal incision palatopharyngoplasty versus the same procedure performed simultaneously with an individually tailored pharyngeal flap or sphincter pharyngoplasty for correcting velopharyngeal insufficiency associated with submucous cleft palate.

Speech outcomes following Sommerlad primary palatoplasty: Results of the Ghent University Hospital.

OBJECTIVE AND SUBJECTS: Speech outcomes were described for 16 patients with cleft palate (mean age: 5.4 years) following Sommerlad primary palatoplasty performed by a single surgeon of the Ghent University Hospital. These speech outcomes were compared with those of an age and gender matched control group without cleft palate (mean age: 5.3 years). METHODS: Speech intelligibility/distinctiveness, resonance, nasal airflow and articulation, were perceptually evaluated. Additionally, nasalance values and the NSI 2.0 were determined. RESULTS: In seven patients, speech intelligibility/distinctiveness was disordered. Hypernasality was present in twelve participants, whereas nasal emission and nasal turbulence were perceived in thirteen and five patients respectively. Both perceptual and instrumental speech evaluations were significantly poorer in the patient group in comparison to the control group. CONCLUSIONS: Patients still present with both obligatory and compensatory speech disorders following Sommerlad's palatoplasty. In the future, a Dutch speech assessment protocol will be developed in order to standardize follow-up of these patients and to allow for within-center and inter-center comparisons.

Ear, nose and voice problems in children with orofacial clefts.

The purpose of this study was to compare the prevalence of ear, nose and particularly voice problems in groups of children with cleft palate (CP) and with unilateral cleft lip, alveolus and palate (UCLP). On the basis of history, regular otorhinolaryngological examinations and hearing tests, the prevalence of different pathologies was assessed in 80 CP children (35 boys and 45 girls) and 73 UCLP children (47 boys and 26 girls). Ear pathology was reported in 53.8 per cent of CP children and in 58.9 per cent of UCLP children. Nasal breathing was impaired in 14 CP (17.5 per cent) and 36 UCLP (49.3 per cent) children. Dysphonia was detected in 12.5 per cent of CP and 12.3 per cent of UCLP children. In 9.2 per cent of all cleft children, functional voice disorder caused a hoarse voice. Two-thirds of cleft children with functional dysphonia had protracted hearing loss. Therefore, ENT specialists must take an active role early in the treatment of children with clefts.

What more can be done to popularize phonosurgical ideas in everyday handling of vocal folds?

This paper is focused on vocal fold surgery with phonosurgical intent. The aim of this review is to broaden phonosurgical knowledge, spread the ideas of the European Laryngological Society (ELS) on phonosurgery and translate the layered structure and physiology of the vocal fold described in Hirano's classic body-cover model into the graphic illustration of the "fluttering sleeve" created by Dikkers. In numerous countries, where phonosurgery is a relatively novel field of knowledge or still in its infancy, simple patterns and plain associations will serve the best in popularizing sophisticated vocal fold anatomy and preservation surgery and converting it into everyday routine.

The effect of ankyloglossia on speech in children.

OBJECTIVE: We wanted to determine whether ankyloglossia is associated with articulation problems and the effect of frenuloplasty on speech and tongue mobility. STUDY DESIGN: We conducted a prospective study of 30 children aged 1 to 12 years with ankyloglossia undergoing frenuloplasty. Outcomes were assessed by measurements of tongue mobility, speech evaluation, and parent questionnaires. RESULTS: Mean tongue protrusion improved from 14.2 mm preoperatively to 25.8 mm postoperatively (P < 0.01). Similarly, mean tongue elevation improved from 5.2 to 22 mm (P < 0.01). Preoperative speech pathology evaluation documented articulation problems thought due to ankyloglossia in 15 of 21 children. Postoperative evaluation in 15 of these children showed improvement in articulation in 9, no change in 4 who had normal speech preoperatively, and an ongoing articulation disorder in 2. Parent perception of speech intelligibility on a scale of 1 to 5 improved from 3.4 to 4.2 (P < 0.01). CONCLUSION: Tongue mobility and speech improve significantly after frenuloplasty in children with ankyloglossia who have articulation problems.

Articulatory function in glossectomized patients with immediate reconstruction using a free jejunum flap.

Postoperative articulation in 18 glossectomized patients was investigated. The subjects were: 5 cases of tongue tumour, 7 cases of tumour of the anterior part of the floor of the mouth and 6 cases of tumour of the lateral part. A new modification of the Freiburger test for speech audiometry was used as test material. Then the articulatory function was assessed according to an overall score based on 180 monosyllables, the manner of production of 171 initial consonants and the place of production of 85 glossal sounds. The cases of tumour of the tongue and the lateral part of the floor of the mouth had excellent scores in all classes of sounds, which were compatible with the normative data. The subjects of tumour of the anterior part of the floor of the mouth had low overall scores, low scores for plosive and affricative sounds, and very low scores for sounds produced with the rear of the tongue. The relation between the site or amount of resection and subsequent articulation was significantly poor in all categories of sounds for the cases of anterior tumour, particularly in the movement of the posterior portion of the tongue even though it was not involved in the operation. In all groups there was a weak negative relation between the amount of resection and postoperative articulation. In reviewing the literature, reconstruction with a free jejunum flap was considered to lead to better articulation than reconstruction by other techniques. The need to assess postoperative function objectively was stressed, to compare the postoperative functions and to determine the indications for the reconstructive technique.

Facial animation in children with Möbius syndrome after segmental gracilis muscle transplant.

Möbius syndrome is a complex congenital anomaly involving multiple cranial nerves, including the abducens (VI) and facial (II) nerves, and often associated with limb anomalies. Muscle transplantation has been used to address the lack of facial animation, lack of lower lip support, and speech difficulties these patients experience. The purpose of this study was to investigate the results of bilateral, segmental gracilis muscle transplantation to the face using the facial vessels for revascularization and the motor nerve to the masseter for reinnervation. The outcome of the two-stage procedure was assessed in 10 consecutive children with Möbius syndrome by direct interview, speech assessment, and oral commissure movement. Preoperative data were collected from direct questioning, viewing of preoperative videotapes, notes from prior medical evaluations, and rehabilitation medicine and speech pathology assessments. All of the patients developed reinnervation and muscle movement. The children who described self-esteem to be an issue preoperatively reported a significant posttransplant improvement. The muscle transplants produced a smile with an average commissure excursion of 1.37 cm. The frequency and severity of drooling and drinking difficulties decreased postoperatively in the seven symptomatic children. Speech difficulties improved in all children. Specifically, of the six children with bilabial incompetence, three received complete correction and three had significant improvement. Despite the length and complexity of these procedures, complications were minimal. Muscle transplantation had positive effects in all problematic areas, with a high degree of patient satisfaction and improvement in drooling, drinking, speech, and facial animation. The surgical technique is described in detail and the advantages over regional muscle transfers are outlined. Segmental gracilis muscle transplantation innervated by the motor nerve to the masseter is an effective method of treating patients with Möbius syndrome.

Surgical correction of velopharyngeal insufficiency with and without compensatory articulation.

The final speech outcome in cleft palate patients depends on two elements: normalization of nasal resonance and correction of compensatory articulation (CA). The purpose of this paper is to demonstrate whether early surgical correction of velopharyngeal insufficiency (VPI) may decrease total time of speech therapy (ST) necessary to completely eliminate CA. A group of 29 cleft palate patients in which VPI and CA were demonstrated, were selected for the study group. Fourteen patients were randomly selected and underwent surgical correction of VPI as soon as placement of articulation during isolated speech was normal. The other 15 patients underwent speech therapy aimed to correct CA, these patients were followed until articulation was normal during connected speech. At this point in time they underwent surgical correction of VPI as the other 14 patients. Success rate for correcting VPI after the operation was not significantly different for both groups. Furthermore, total time of ST was not significantly different for both groups. It is concluded that normalization of nasal resonance before articulation is corrected during connected speech does not seem to reduce total time of ST necessary to completely correct CA in cleft palate patients.

The correlation between training and skill of the surgeon and reoperation rate for persistent cleft palate speech.

The correlation between the surgeons training and skill and the speech after primary repair was tested using the reoperation rate as a measure for success in 439 cleft palate/cleft lip and palate (CP/CLP) patients operated at the average age of 22 months by 4 specialists and 4 residents. The reoperation rate for residents was 11-60% (av. 36) and for specialists 13-31% (av. 19). The relative reoperation rates in CP/CLP were 20/19% for specialists but 35/38% residents. In groups consisting of the four with the best (A) and the four with the worst results (B) the reoperations rate in group A was 16% for CP and 13% for CLP, but in group B 37/44%. As the residents became specialists, the degree of their improvement varied greatly. Thus both the training and skill are important for the patients speech, but they are not necessarily synonymous terms.

Impact of malocclusion and orthognathic reconstruction surgery on resonance and articulatory function: an examination of variability in five cases.

Articulatory patterns and nasal resonance were assessed before and 6 months after orthognathic reconstruction surgery in five patients with dentofacial deformities. Perceptual and physiological assessments showed disorders of nasality and articulatory function preoperatively, two patients being hyponasal, and one hypernasal. Four patients had mild articulatory deficits, and four had reduced maximal lip or tongue pressures. Operation resulted in different patterns of change. Nasality deteriorated in three patients and articulatory precision and intelligibility improved in only one patient and showed no change in the other four. Operation improved interlabial pressures in three patients, while its impact on tongue pressures varied, being improved in one case, deteriorating in one, and remaining unchanged in the other three. The variability in the results highlights the need for routine assessment of speech and resonance before and after orthognathic reconstruction.

Effect of method of cleft palate repair on the quality of speech at the age of 6 years.

Two methods of primary palatal repair were compared for the effect that they had on the speech of 6 year old children with cleft (lip and) palate. A Veau-Wardill-Kilner V to Y pushback operation was done for 43 children (group V) and the Cronin modification for 60 children (group C) between the ages of 12 and 18 months. The groups were compared with respect to the quality of speech assessed clinically by perception, by instrumental measures of nasalance, and by the number of velopharyngeal flaps required. The quality of speech was assessed in terms of perceived signs of velopharyngeal insufficiency: hypernasality, audible nasal air emissions, weakness of plosives and compensatory articulations. Hypernasality was significantly more common in group V (16/33, 48%) than in group C (11/49, 22%) (p = 0.01). The number of velopharyngeal flaps and the nasalance scores derived from most of the individual test sentences were similar in the two groups. The mean nasalance score for the whole set of test sentences was significantly higher in group V.