Management of Cleft-Related Speech Differences.

Background:Velopharyngeal dimensions change as a child with cleft palate (CP) grows. The aim of this study was to assess if the decision for velopharyngeal insufficiency (VPI) surgery can be made by the age of 3 years among CP children with moderate-to-severe VPI. In addition, we sought to clarify if speech therapy before VPI surgery is beneficial for VPI speech characteristics.Methods:This retrospective study reviewed documentation of children with moderate-to-severe VPI at age 3 years who did not undergo VPI surgery until age 5 years. Based on the national cleft register, 959 patients with syndromic and nonsyndromic CP were treated by the craniofacial team at Helsinki University Hospital, Finland between 2000 and 2014. Eighty-six patients fulfilled the study inclusion criteria. The speech pathologist evaluated velopharyngeal function at age 3, 5, and 8 years.Results:Of the 86 children presenting with moderate-to-severe VPI at age 3 years, 94% still had moderate-to-severe VPI at age 5 years, even though speech therapy was offered to 77%. Of those whose velopharyngeal function improved by age 5 years, function regressed to incompetent over time. Overall, 93% underwent VPI surgery and 82% underwent VPI surgery between ages 5 and 8 years. Only 23% at age 8 years still had moderate-to-severe VPI. Speech therapy alone did not improve VPI speech characteristics.Conclusions:Moderate-to-severe VPI did not improve from 3 to 5 years or improved but subsequently relapsed. This suggests that the decision for VPI surgery can be made for children aged 3 years with moderate-to-severe VPI.

BACKGROUND: Craniofacial microsomia (CFM) is characterized by malformations of facial structures that are derived from the first and second brachial arches. Although hearing, occlusion, and facial paralysis are the most typical functional considerations for CFM, abnormalities in speech, including velopharyngeal insufficiency (VPI), have also been sparingly reported in several studies. As a result, the purpose of this multicenter study was to analyze the prevalence and management of VPI in patients with CFM. Furthermore, this study sought to investigate the effects of concomitant cleft lip and/or palate (CL/P) on VPI in CFM patients. METHODS: A retrospective chart review of patients from the University of California, Los Angeles Craniofacial Clinic and the Orthopaedic Institute for Children in Los Angeles was conducted. Inclusion criteria included patients who were diagnosed with CFM, first and second brachial arch syndrome, oculo-auriculo-vertebral sequence, facio-auriculo-vertebral syndrome, or Goldenhar syndrome. Patients with isolated microtia were excluded from this study. Included CFM patients were stratified based on the presence or absence of CL/P, and all patients were evaluated for VPI, methods of diagnosis, speech therapy, and surgery. All patients received at least 1 thorough evaluation by a speech pathologist and were diagnosed clinically with VPI if they were noted to have any hypernasal speech, nasal air emission, or nasal turbulence. Chi-square tests and Levene’s test (P ≤ 0.05) were used for analysis. RESULTS: Overall, 78 patients with CFM (48 males, 61.5%) were assessed for VPI, aged 4–34 years old at time of review. In the entire cohort, 22 (28.2%) patients were found to be diagnosed with VPI. Of the 78 patients, 8 (10.3%) patients had concomitant CL/P. Of the 70 CFM patients without CL/P, 14 (20.0%) had VPI. Eight (57.1%) of these patients were recommended for nasoendoscopy, whereas none of these patients required any corrective VPI surgery. Comparatively, all 8 CFM with CL/P patients were diagnosed with VPI and recommended for nasoendoscopy, significantly higher rates than those without CL/P. Furthermore, 6 (75.0%) of these patients eventually underwent VPI surgery, significantly more than those without CL/P. CONCLUSIONS: This study establishes an overall rate of VPI in CFM at 28.2%, with the largest cohort of CFM looking into VPI in the literature. All of the CFM patients with CL/P had VPI, with a majority requiring surgery, compared with only a fifth of CFM patients without CL/P having VPI and none needing surgery. Findings from this study highlight VPI as a common problem in CFM patients who should be diagnosed and managed early on. In addition, this study displays CL/P as a risk and severity factor for VPI.

To compare speech symptoms of velopharyngeal insufficiency (VPI) and incidence of secondary speech surgery in 10-year-old Finnish children with unilateral cleft lip and palate (UCLP) following primary palatal surgery using 2 surgical methods. Single center analysis within the Scandcleft multicenter randomized controlled trial of primary surgery for UCLP. Patients comprised 79 nonsyndromic 10-year-old children with UCLP. Two randomized surgical methods were used in the primary palatal surgery: soft palate closure at 4 months and hard palate closure at 12 months (Arm A) and closure of both the soft and hard palate at 12 months (Arm C). Speech symptoms of VPI were analyzed from standardized video recordings by 2 experienced speech pathologists. The incidences of surgery for correcting VPI, fistula closure, and speech therapy were evaluated retrospectively from patient records. No differences in speech symptoms of VPI, need for VPI surgery or speech therapy were found between the surgical methods. Of all 79 children, 33% had had VPI surgery and 61% had speech therapy. The number of fistulas was significantly higher in Arm A (25%) than in Arm C (2%). Moderate to severe speech symptoms of VPI (hypernasality, continuous nasal air leakage, weak pressure consonants, and/or compensatory articulation) were found in 11% of the children. No differences were present between groups in speech symptoms of VPI or need for VPI surgery or speech therapy between the 2 surgical methods. One third of the children had undergone VPI surgery. Most of the children (89%) had good or relatively good speech.

Surgery for velopharyngeal insufficiency: The outcomes of the University Hospitals Leuven

Primary Palatoplasty: Prevalence of Velopharyngeal Insufficiency at a Single Institution

A 16-item questionnaire designed to survey opinions on the management of velopharyngeal insufficiency (VPI) was distributed to all members (N = 296) of the American Cleft Palate Association who were speech-language pathologists. Questionnaires were completed by 173 respondents (58.4 percent). There were differences of opinion among speech-language pathologists on various management issues related to VPI, including the value of instrumental assessment of VPI, the importance of oral examination of velopharyngeal function, and the effectiveness of speech therapy in the treatment of VPI. The implications of these findings for clinical training in VPI are discussed.

Management of orofacial clefts requires a comprehensive approach to address the multifaceted aspects of possible aesthetic and functional deficits. Many children with cleft palate with or without cleft lip continue to have speech abnormalities that can affect socialization, education, and childhood development. An interdisciplinary cleft team ideally manages most orofacial clefts and can include members from the fields of facial plastic surgery, otolaryngology, speech and language pathology, pediatrics, nursing, audiology, genetics, oral surgery, orthodontics, dentistry, and social work. These teams follow a relatively established timeline and algorithm for each of the discrete steps of orofacial cleft treatment. Cleft lip repair is often performed after 3–5 months of age. Palatoplasty is delayed after 8–14 months of age. Speech and language pathology assessment and therapy are targeted as the vocabulary develops (2–5 years old). This special issue deals with the cleft surgeon and speech therapists role in treatment of velopharyngeal dysfunction (VPD), which is often related to velopharyngeal insufficiency (VPI). This lack of coordinated closure of the soft palate to the posterior pharyngeal wall is often a sequela of cleft palate, even after primary repair. One paper from this issue titled “Nonlinear dynamic analysis of vowels in cleft palate children with or without hypernasality” reports on cephalometric differences between the skull base and velopharyngeal anatomy in patients with unilateral cleft lip and palate compared to normal controls. These data contribute to the existing literature of abnormal skull base anatomy and inclination in children with velocardiofacial syndrome, which often associated with VPD. The next paper titled “Noncleft velopharyngeal insufficiency: etiology and need for surgical treatment” analyzes those children with VPD without obvious orofacial clefting, and assesses the etiologies and potential treatment options. This allows for comparison to the traditional orofacial cleft-related VPD management. The velopharyngeal workup is often a coordinated assessment by the cleft surgeon and speech pathologists. It can include subjective assessment, which is the subject of the next two papers. First, the next paper titled “Nonlinear dynamic analysis of vowels in cleft palate children with or without hypernasality” assesses the relationship between two speech assessment tools, Lyapunov exponents, and Nasalance scores in the presence of hypernasal speech. Furthermore, an additional paper titled “Assessment of single-word production for children under three years of age: comparison of children with and without cleft plate” presents a case-control testing of a single word assessment tool in children less than 3 years of age with cleft palate, which indentified speech differences in error patterns, consonants, articulation, and accuracy between children with and with clefts. Objective assessment of VPD also can include either fluoroscopic speech examination or nasopharyngoscopy to characterize the pattern of VPD and target a surgical goal. The next paper titled “Objective assessment of hypernasality in patients with cleft lip and palate with the nasalView system: a clinical validation study” assesses the validity and reliability of a new tool for hypernasality testing called NasalView. Speech and language therapy is instituted to address typical compensatory speech patterns seen in children with cleft palate (e.g., glottal stops). If hypernasal speech is not responsive to speech and language therapy, secondary speech surgery is warranted to address hypernasality in this time period. Surgical options may include a superiorly based pharyngeal flap, dynamic sphincter pharyngoplasty, or posterior pharyngeal wall augmentation. Occasionally, a palate-lengthening procedure (Furlow double-opposing Z-plasty) is performed. These procedures can limit nasal air emissions, but potential obstructive sleep apnea from excessive nasal obstruction is a risk. The risk of sleep apnea after surgically treating the velopharynx may be decreased if the tonsils and adenoids are addressed preemptively. Before pharyngeal flap surgery, some surgeons perform tonsillectomy to limit the potential variability of speech and airway changes that comes with fluctuating tonsillar hypertrophy, tonsillitis, or upper respiratory infections. The use of tonsillectomy in the face of VPI in children with cleft palate is somewhat controversial and is the topic of the last paper “Speech outcomes after tonsillectomy in patients with known velopharyngeal insufficiency”. The guest editors are pleased to present a collection of papers dealing with management of the speech-related difficulties in children with orofacial clefts. In this era of the expanding role of evidenced-based medicine, the effectiveness of treatments can only be monitored and improved by assessment with valid and consistent outcome measures, which are reviewed in this issue. Travis T. Tollefson David White James Brookes Steven Goudy

Sir: The article by Becker et al.1 on the use of functional magnetic resonance imaging to identify differences in functional neuroanatomy involving speech in subjects with and without cleft lip and palate has potential for shedding new light on the speech problems of children with cleft lip and palate. However, data not included in the article, and several of their statements, reveal the authors’ narrow intracranial viewpoint. For instance, they say, “No factors have yet been identified that positively predict who will develop [speech and language dysfunction].” An incompetent velopharyngeal valve, caused by the cleft and too often not cured by palatoplasty, is obviously predictive; essentially all children with isolated (nonsyndromic) cleft lip and palate, and the great majority with a cleft and another congenital anomaly, would have developed normal speech had their palates not been cleft. The cerebral differences identified in the study could be attributable either to inherent brain morphology or to the postpartum effects on brain morphology of learning speech with an anatomically crippled speech mechanism. However, the authors do not discuss the relationship of the direct effects of velopharyngeal insufficiency (nasal escape and hypernasality) and the compensatory speech articulations learned (stored intracranially) to compensate for the incompetence of the velopharyngeal valve. This relationship could well be central to the differences described by the study. The study patients’ clefts were repaired from approximately 1988 to 1998 and thus may have been in that era’s Washington University intravelar veloplasty/no intravelar veloplasty study,2 in which fewer than one-third achieved velopharyngeal competence, and over half, 54 percent (39 of 72), had lesser degrees of velopharyngeal insufficiency deemed not severe enough to need secondary surgery. However, nowhere in the article are the velopharyngeal function and the compensatory articulations of the 12 patients/subjects quantified. It is believed that the age at which velopharyngeal competence is achieved is a factor in speech outcome, yet the study did not provide data on the age of those subjects who had a successful primary palatoplasty, the age and speech outcome for any who needed secondary surgery for velopharyngeal insufficiency, and which subjects had undergone speech therapy. One corroboration of the importance of velopharyngeal function on speech comes from the fact that the large majority of patients with submucous cleft palate have velopharyngeal competence and normal speech, and only a small minority have velopharyngeal insufficiency and abnormal speech.3 A study of functional neuroanatomy between the patients in these two groups, all of whom have the anatomical abnormalities of a cleft soft palate, or between patients whose successful early palatoplasty permitted development of normal speech without speech therapy versus patients who much later underwent surgery for velopharyngeal insufficiency, might be revealing. The authors’ claim that “The palatal anatomy that is dysfunctional for a speech task is fully functional for a swallowing task” supports a central nervous component to speech function, although it has long been known that the actions of swallowing and of velopharyngeal closure in speech are quite different anatomically and functionally4; one must breathe to vocalize for speech but cannot breathe during swallowing. The level of closure, the port that is closed, the muscles involved, and the reasons for the two functions are different. Also, the reflux of food and liquid into the nose with swallowing is evidence that the swallowing mechanism is not ‘fully functional” in the presence of velopharyngeal insufficiency. The findings described in this work are very interesting, but the authors need to be much more cognizant of the basic cause for the speech problems: a velopharyngeal valve that cannot close rapidly and completely. Leonard T. Furlow, Jr., M.D. University of Florida College of Medicine 3001 N.W. 28th Terrace Gainesville, Fla. 32605 DISCLOSURE The author has no financial relationship with anyone associated with the article to which his comments refer, except as a donor to Washington University Medical School, from which he graduated.

A simple algorithm is applied to treat velopharyngeal insufficiency. The purpose of this study was to assess its success rate and complications. The diagnosis includes speech perceptual assessment and nasopharyngoscopy, focusing on velopharyngeal closure ratio. The treatment is composed of a double-opposing Z-plasty for marginal velopharyngeal insufficiency or a pharyngeal flap for moderate to severe velopharyngeal insufficiency. A retrospective chart review was conducted for 84 consecutive nonsyndromic postpalatoplasty patients undergoing velopharyngeal insufficiency surgery from August of 2007 to December of 2014. The demographic, perioperative, and follow-up data were collected. Statistical analyses were performed. Mean age at velopharyngeal insufficiency surgery was 7.0 years. The overall improvement rate for patients was 86.9 percent. Nine patients in the double-opposing Z-plasty group and two patients in the pharyngeal flap group were refractory to velopharyngeal insufficiency surgery. The improvement rates for each surgical group were 80.4 percent for the double-opposing Z-plasty group and 94.7 percent for the pharyngeal flap group. There were no significant differences in postoperative velopharyngeal function between the coronal and noncoronal groups. Airway-associated complications were observed in nine patients (10.7 percent). The complications in the double-opposing Z-plasty group were observed in two patients (4.3 percent), and none of the patients presented obstructive sleep apnea. Seven patients (18.4 percent) in the pharyngeal flap group showed postoperative snoring, and one (2.6 percent) of them presented with obstructive sleep apnea. The authors' algorithm is a simple patient- and surgeon-friendly strategy to obtain satisfactory improvement of velopharyngeal function for velopharyngeal insufficiency patients, with a low risk of airway complications. Therapeutic, IV.

The aim of this study was to identify current trends in clinical assessment and management of stress velopharyngeal insufficiency (VPI) in wind musicians. This was an online two-round Delphi survey of health practitioners familiar with assessing and treating musicians with stress VPI. Fourteen specialists (seven otolaryngologists and seven speech-language pathologists) from four countries participated in the Delphi survey. From the first round questionnaire, 32 items were identified as being causes, assessment tools, diagnostic indicators, and treatment methods for stress VPI. The second round questionnaire revealed that prolonged exposure to high intra-oral pressures was important in determining the cause of stress VPI. The most important assessment tools for stress VPI were case history and nasendoscopy. The most important indicator for stress VPI was self-reported symptoms. There was no clear agreement identified on the management methods for stress VPI for musicians. However, the trend followed by most of the survey participants was a combination of conservative management approaches (including rest or watch and wait, speech-language pathology intervention, velopharyngeal muscle training, and changes to the instrument or reed), and then, if symptoms persist, to use injection pharyngoplasty or pharyngeal flap. This survey demonstrates that no standard management protocol currently exists for musicians diagnosed with stress VPI, but provides current trends in the assessment and management which can be used in future guidelines for health professionals who treat wind musicians.

The purpose of this study was to analyze the prevalence, diagnosis, and management of velopharyngeal insufficiency (VPI) in patients with craniofacial microsomia (CFM).Craniofacial microsomia patients 13 years of age and above treated at 2 centers from 1997 to 2019 were reviewed retrospectively for demographics, prevalence of VPI, and management of VPI. Patients with isolated microtia were excluded. Comparisons were made between patients with and without VPI using chi-square and independent samples t tests.Among 68 patients with CFM (63.2% male, mean 20.7 years of age), VPI was diagnosed in 19 patients (27.9%) at an average age of 7.2 years old. Among the total cohort, 61 patients had isolated CFM, of which 12 (19.6%) were diagnosed with VPI. Of the patients with isolated CFM and VPI, 8 patients (66.7%) were recommended for nasoendoscopy, of which only 2 patients completed. Seven isolated CFM patients (58.3%) underwent speech therapy, whereas none received VPI surgery. In contrast, 7 patients were diagnosed with both CFM and cleft lip and/or palate (CL/P), all of whom had VPI and were recommended for nasoendoscopy, with 5 (71.4%) completing nasoendoscopy, 6 (85.7%) undergoing speech therapy, and 6 (85.7%) undergoing corrective VPI surgery. Overall, we demonstrated that VPI was present in 27.9% of all CFM patients. On subset analysis, VPI was diagnosed in 20% of patients with isolated CFM and 100% of patients with CFM and CL/P. In addition, despite clinical diagnosis of VPI, a sizeable proportion of isolated CFM patients did not undergo therapy or surgical interventions.

Influence of speech aid prosthesis with speech therapy on speech outcomes in adult patients with persisting velopharyngeal insufficiency: A retrospective analysis

Case historyA 5-year-old girl presented with a suspected palatal abnormality, first observed by her general practitioner during a routine examination at 4 years. She had a history of conductive hearing...

The field of speech and language pathology (SLP) expanded to a wide range of specialities, leading to a global trend to decrease the time spent on specific courses on children with cleft palate, with or without cleft lip (CP±L) in SLP education programmes. The lack of CP±L courses has resulted in a global shortage of well-trained SLPs to deliver high-quality services to this population. Therefore, alternative training formats are needed. This study aimed to assess the training needs of Flemish speech and language pathologists (SLPs) working with children with CP±L by examining: (1) their current employment situation, experience and perceived competence regarding CP±L; (2) their preferences for the content, sources and organisation of continuing education on CP±L and (3) potential incentives and barriers to attend continuing education on CP±L. A self-constructed online survey in QualtricsXM, based on existing literature, was utilised. The study employed a descriptive, quantitative approach, supplemented with open-ended questions to enrich and deepen the quantitative data. The 158 respondents had a mean work experience of 10 years, a median of 7 years and a mode (most frequently occurring value) of 5 years. Of these 158 respondents, 132 (83.5%) were young SLPs with professional experience ranging from 0 to 15 years. Of these, 53.8% (85/158) had previously treated one or more children with CP±L, of whom 71 (83.5%) had a caseload of 0-3 children within the last 5 years. The mean caseload for the 85 SLPs with experience was 4.74 cases, with a median of one child and a mode of one. Of the 85 respondents with experience, 9.4% (8/85) felt highly competent in treating feeding problems, while 58.8% (50/85) felt highly capable in treating speech and language problems. However, 60% (95/158) of the SLPs would refer children with CP±L, especially when having feeding problems or severe speech and language problems, such as compensatory articulation disorders (CADs) or submucosal cleft, as they feel a lack of competence. Two-thirds (63.6%, 96/151) of the respondents who answered this question expressed a desire for continuing education in the assessment and treatment of children with CP±L. Although many Flemish SLPs perceived themselves as highly competent in treating speech and language problems in children with CP±L, they reported a lack of competence in treating complex or severe cases. They expressed a strong demand for specific, highly practical continuing education on CP±L, taught by experts in the field and with personal guidance. Based on the existing literature, our experience with CP±L and the results of this survey, we developed a continuing education programme on CP±L as an alternative educational format, tailored to the needs of Flemish community SLPs. What is already known on the subject Treating children with CP±L is complex and requires high-quality care from specialised SLPs with sufficient clinical experience. However, there is a global trend to reduce dedicated coursework on CP±L in SLP training programmes. Instead, the subject is often briefly covered in general courses or offered as an elective. As a result, there is a shortage of well-trained SLPs, creating an urgent need for alternative training formats. What this paper adds to the existing knowledge This study reveals that Flemish Community SLPs feel insufficiently trained to assess and treat children with CP±L who exhibit complex or severe problems, such as feeding problems, compensatory articulation disorders (CAD), velopharyngeal insufficiency or submucosal cleft palate. They have a strong need for theoretical knowledge and practical continuing education, preferably provided by experts in CP±L. They want a 1-day or multi-day training course that utilises extensive video footage, personal coaching, opportunities to observe experts and even an internship. Additionally, they want an online platform to collect and disseminate all knowledge and expertise. What are the potential or actual clinical implications of this work? Given the global decline in specific CP±L courses in SLP programmes, SLPs feel inadequately prepared to assess and treat these children correctly. This increases the risk that no results will be achieved or that undesirable results will occur. To prevent this, alternative training formats are needed. Based on this needs analysis, a training programme was developed for community SLPs, tailored to their needs to enable them to provide high-quality speech therapy services.

<sec><st>Actualite and the aim</st> Velopharyngeal insufficiency is one of the main causes of speech disorders in children with congenital cleft palate, which leads to speech disruption in the form of nasality, dysarthria and also participate in compensatory mechanisms of articulation. The aim was evaluating results of complex treatment in velopharyngeal insufficiency, in case of restoring the nerve-muscle complex of velopharyngeal ring. </sec> <sec><st>patients and methods</st> The study involved two groups of children operated on congenital cleft palate and velopharyngeal insufficiency. The main group includes 40 patients who got the complex treatment: neurological treatment, physiotherapy, massage courses of maxillofacial region with intraoral massage with parallel speech therapy. There were 35 patients in the comparison group. In this group only speech therapy was performed. </sec> <sec><st>Results</st> After the rehabilitation course the velopharyngeal ring closing in the main group improved on 56%, speech improved on 49%. In the comparison group the velopharyngeal ring closing improved on 38%, speech on 35%. Nasality of speech in the main group decreased on 45%, in the other group on 29%. For the best results patients were appointed repeated courses of rehabilitation. </sec> <sec><st>Conclusion</st> The treatment of velopharyngeal insufficiency in the postoperative period is aimed at restoring the anatomical and physiological function of the velopharyngeal ring. Velopharyngeal ring is neuromuscular complex and restoration of its function in velopharyngeal insufficiency with simultaneous course of speech therapy, neurology, physiotherapy gives the most possible outcome of rehabilitation. </sec>