Influence of an Intensive Speech Therapy Program on the Speech of Individuals with Cleft Lip and Palate

Abstract Introduction Compensatory articulations are speech disorders due to the attempt of the individual with cleft palate/velopharyngeal dysfunction to generate intraoral pressure to produce high-pressure consonants. Speech therapy is the indicated intervention for their correction, and an intensive speech therapy meets the facilitating conditions for the correction of glottal stop articulation, which is the most common compensatory articulation. Objective To investigate the influence of an intensive speech therapy program (ISTP) to correct glottal stop articulation in the speech of individuals with cleft palate. Methods Speech recordings of 37 operated cleft palate participants of both genders (mean age = 19 years old) were rated by 3 experienced speech/language pathologists. Their task was to rate the presence and absence of glottal stops in the 6 Brazilian Portuguese occlusive consonants (p, b, t, d, k, g) distributed within several places in 6 sentences. Results Out of the 325 pretherapy target consonants rated with glottal stop, 197 (61%) remained with this error, and 128 (39%) no longer presented it. The comparison of the pre- and posttherapy results showed: a) a statical significance for the p1, p2, p3, p4, t1, k1, k2 and d6 consonants (McNemar test; p < 0.05); b) a statistical significance for the p consonant in relation to the k, b, d, g consonants and for the t consonant in relation to the b, d, and g consonants (chi-squared test; p < 0.05) in the comparison of the proportion improvement among the 6 occlusive consonants. Conclusion The ISTP influenced the correction of glottal stops in the speech of individuals with cleft palate.

Auditory-perceptual training for the assessment of hypernasality in cleft palate speakers: an integrative literature review / Treinamento perceptivo-auditivo para a avaliação da hipernasalidade de fala em indivíduos com fissura labiopalatina: uma revisão integrativa da literatura

ABSTRACT Purpose: to describe the auditory-perceptual training for the assessment of hypernasality in individuals with cleft lip and palate. Methods: an integrative literature review in the databases Virtual Health Library, SciELO, and PubMed, aimed to answer the following guiding question: 1) What are the characteristics of auditory-perceptual training to assess hypernasality in individuals with cleft lip and palate? Articles in Portuguese and English, available in full access, without the restriction of the publication date, which presented programs of training for speech hypernasality, unprecedented, adapted, or replicated, were included. The pursuit of descriptors, selection, extraction, and synthesis of data was performed by three independent evaluators. Literature Review: 10 articles were included in this study, based on established criteria. Five articles investigated the effectiveness of training on speech analysis by listeners, regardless of experience level. Another five articles pertained to training when validating speech assessment protocols. Consensus analyses and reference samples were the most used training reported. Perceptual rating of phrases, using the equal appearance scale and in person training, was the most reported one. Conclusions: the auditory-perceptual training of listeners to identify hypernasality showed variability in the proposed strategies, particularly when proposed for non-experienced listeners. The difficulty in maintaining acquired skills in the long term is pointed out.

RESUMO Objetivo: descrever as características dos treinamentos perceptivo-auditivos para a avaliação da hipernasalidade em indivíduos com fissura labiopalatina. Métodos: revisão integrativa de literatura nas bases de dados Biblioteca Virtual da Saúde, SciELO e PubMed que visou responder a seguinte pergunta norteadora "Quais são as características dos treinamentos perceptivos-auditivos para avaliação da hipernasalidade em indivíduos com fissura labiopalatina?". Foram incluídos artigos em português e inglês, disponíveis na íntegra, sem restrição de data de publicação, que apresentassem programas de treinamento para hipernasalidade, inéditos, adaptados ou replicados. A busca dos descritores, seleção, extração e síntese dos dados foram feitas por três avaliadores independentes. Revisão da Literatura: foram incluídos dez artigos com base nos critérios estabelecidos. Cinco artigos investigaram o efeito do treinamento na análise perceptiva de ouvintes, com ou sem experiência. Outros cinco utilizaram treinamentos de fonoaudiólogos, ao validar protocolos de avaliação da fala. Análises consensuais e amostras de referências foram os treinamentos mais empregados. Julgamentos perceptivos de frases, usando escala de intervalos iguais, em modalidade presencial foram os mais descritos. Conclusão: treinamentos perceptivo-auditivos para identificação da hipernasalidade variaram, particularmente, em sua duração e ouvintes incluídos. A dificuldade em manter habilidades adquiridas a longo prazo é apontada.

Efeito do treinamento perceptivo-auditivo na classificação da hipernasalidade de fala / Effect of perceptive-auditory training on the classification of speech hypernasality

RESUMO Objetivo Analisar o efeito de um treinamento perceptivo-auditivo de fonoaudiólogas sem experiência na classificação da hipernasalidade de fala de indivíduos com fissura labiopalatina e comparar a classificação da presença e grau de hipernasalidade realizadas dessas fonoaudiólogas (com a avaliação padrão-ouro), antes e depois do treinamento perceptivo-auditivo. Método Três fonoaudiólogas sem experiência analisaram 24 amostras de fala de alta pressão de indivíduos com fissura labiopalatina, antes e depois de treinamento perceptivo-auditivo, usando escala de quatro pontos. As amostras de fala correspondiam a seis amostras de cada grau de hipernasalidade. Entre as análises, as fonoaudiólogas receberam treinamento perceptivo-auditivo. Houve acesso às amostras de referência e feedback de respostas corretas quanto ao grau de hipernasalidade no treinamento. Resultados Não houve diferença significativa na porcentagem geral de acertos entre os momentos antes e depois do treinamento perceptivo-auditivo. Houve associação e concordância significativa das três avaliadoras com avaliação padrão ouro após treinamento, com aumento da concordância para uma avaliadora (aumento de respostas corretas para os graus ausente e leve). A análise dicotômica dos dados mostrou aumento do índice de concordância Kappa dessa avaliadora. Houve aumento do índice concordância inter-avaliadores para hipernasalidade ausente, leve, e grave, porém sem significância estatística. Conclusão O treinamento perceptivo-auditivo não resultou em melhora significativa da classificação da hipernasalidade de fala pelas fonoaudiólogas sem experiência, embora a análise individual dos dados tenha mostrado que o treinamento favoreceu uma dessas avaliadoras. Novos estudos envolvendo treinamento perceptivo-auditivo gradual e mais extenso poderão favorecer a classificação da hipernasalidade de fala por fonoaudiólogos sem experiência.

ABSTRACT Purpose To analyze the effect of auditory-perceptual training by inexperienced speech-language pathologists in the classification of hypernasality in individuals with cleft lip and palate and compare their classification of hypernasality individually, with the gold standard evaluation, before and after this training. Methods Three inexperienced speech-language pathologists used a four-point scale to assess 24 high-pressure speech samples from individuals with cleft lip and palate, before and after auditory-perceptual training. The speech samples corresponded to six samples of each degree of hypernasality. The speech-language pathologists received auditory-perceptual training during the assessments. They had access to anchor samples and immediate feedback of correct answers regarding the degree of hypernasality in training. Results There was no significant difference in the overall percentage of correct answers when comparing before and after the auditory-perceptual training. There was a significant association and agreement of the three evaluators with a gold standard evaluation after training, with an increase in agreement for a single evaluator for absent and mild degrees of hypernasality. The dichotomous analysis of the data showed an increase in the Kappa Index of Agreement of this evaluator. Although there was an increase in the Index of Agreement between evaluators for absent, mild, and severe hypernasality, this increase did not reach statistical significance. Conclusion The auditory-perceptual training provided did not result in a significant improvement in the hypernasality classification for the inexperienced speech-language pathologists, even though the individual data analysis showed that the training favored one of the evaluators. Further studies involving gradual and more extensive auditory-perceptual training may favor the classification of hypernasality by inexperienced SLPs.

Could speech disorders in children with cleft lip and palate be justified by impaired central auditory skills?

ABSTRACT Purpose: to verify the association between central auditory skills and speech disorders related to velopharyngeal dysfunction. Methods: forty-five children, with repaired non-syndromic cleft lip and palate or cleft lip only, aged 7-11 years old, were divided into three groups: G1 (n=15), children with hypernasality, nasal air emission, and compensatory articulations; G2 (n=15), children with hypernasality and nasal air emission, but without compensatory articulations; and G3 (n=15), children without hypernasality, nasal air emission, and compensatory articulations. The medical records of all participants were analyzed to verify the eligibility criteria and obtain speech assessments, and then, they were submitted to an assessment of central auditory skills. Statistical analysis comprised descriptive and chi-square test with a significance level of 5%. Results: G1 presented a higher occurrence of impairment in central auditory skills differing from the other groups, particularly in the temporal ordering and binaural integration skills. A significant difference was observed among groups in temporal ordering ability. No significant association was found between the use of specific types of compensatory articulations and impaired auditory skills. Conclusion: there was an association between changes in temporal ordering auditory skills and binaural integration in children with velopharyngeal dysfunction, regardless of the presence or type of compensatory articulation found.

Planificación quirúrgica de colgajo faríngeo a medida para insuficiencia velofaríngea secundaria a fisura de paladar: reporte de caso y revisión de literatura / Surgical planning of a tailor-made pharyngeal flap for velopharyngeal insufficiency secondary to a cleft palate: case report and literature review

Resumen La insuficiencia velofaríngea (IVF) es una de las principales secuelas estructurales tras la palatoplastía primaria en casos de fisura de paladar. La IVF se caracteriza por la ausencia de tejido suficiente para lograr un cierre adecuado del mecanismo velofaríngeo durante el habla, lo que conlleva a una resonancia hipernasal y la emisión nasal de aire durante la producción de sonidos orales. Al respecto, el tratamiento ideal para corregir la IVF es quirúrgico, dentro de los cuales el colgajo faríngeo de pedículo superior es uno de los procedimientos más utilizados en nuestro país. Para su realización es fundamental determinar el ancho necesario, lo cual puede ser determinado mediante una videofluoroscopía multiplano (VFMP). Por esto, con el objetivo de potenciar el trabajo multidisciplinario en la corrección quirúrgica de la IVF, a continuación, se presentan los procedimientos de evaluación fonoaudiológica, videonasofaríngoscopía flexible y videofluoroscopía multiplano utilizados para la planificación quirúrgica de un colgajo faríngeo en un adolescente chileno diagnosticado con IVF secundaria a fisura palatina operada. Además, se describe el uso de la VFMP en la planificación quirúrgica del colgajo faríngeo mediante una revisión de literatura.

Abstract Velopharyngeal insufficiency (VPI) is one of the main structural sequelae after primary palatoplasty in cases of cleft palate. VPI is characterized by the absence of sufficient tissue to achieve adequate closure of the velopharyngeal mechanism (VFM) generating hyper-nasal resonance and nasal emission during the production of oral sounds. In cases of cleft palate, the ideal treatment to correct VPI is surgery. The upper pedicle pharyngeal flap is one of the most widely used procedures. To plan it, is essential to determine the appropriate width, which can be determined by means of multiplane videofluoroscopy (MPVF). For this reason, and with the aim of promoting multidisciplinary approach in the surgical correction of VPI, the following procedures such as speech and language evaluation, flexible videonasopharyngoscopy and multiplane videofluoroscopy used for the surgical planning of a pharyngeal flap, in a Chilean adolescent diagnosed with VPI secondary to operated cleft palate, will be presented. In addition, the use of MPVF in pharyngeal flap surgical planning is described through a literature review.

Speech outcomes after palatal closure in 3-7-year-old children / Resultados da fala após o reparo de fenda palatina em crianças de 3 a 7 anos

Abstract Introduction: One of the main goals of the team approach in management of oro-facial clefts is to help the children with cleft palate have adequate speech development. Objective: The present study aimed to investigate the prevalence of articulation and resonance disorders following palate closure in children who were visited for routine examination by the Isfahan Cleft Care Team between 2011 and 2015, and to study the impact of cleft type and age at the time of palatoplasty on speech outcomes. Methods: Clinical records of 180 preschool children with repaired cleft palate were reviewed. The percentage of children demonstrating hypernasality, nasal emission, nasal turbulence, and compensatory misarticulations was calculated. The relationship between cleft type and age at the time of palatal surgery, as independent variables, and speech outcomes were examined. Results: 67.7 and 64.5 percent of the children demonstrated respectively moderate/severe hypernasality and nasal emission, and 71.1 percent produced compensatory misarticulations. Age at the time of palatal repair was significantly associated with compensatory misarticulations and also with moderate/severe hypernasality. The prevalence of compensatory misarticulations, significant hypernasality, nasal emission and also nasal turbulence was not significantly different in various types of cleft. Conclusions: We observed a high prevalence of different speech disorders in preschool children with repaired cleft palate compared to other studies. This can be partly due to late palatal repair in the studied population. Despite many advances in cleft palate management programs in Iran, there are still many children who do not access the interdisciplinary team cares in their early childhood. We should, therefore, try to increase accessibility of appropriate and timely management services to all Iranian children with cleft lip/palate.

Resumo Introdução: Um dos principais objetivos da abordagem em equipe no tratamento das fendas orofaciais é contribuir para que as crianças com fenda palatina tenham um desenvolvimento adequado da fala. Objetivo: Investigar a prevalência de distúrbios de articulação e ressonância após o reparo da fenda palatina em crianças acompanhadas no Isfahan Cleft Care Team entre 2011 e 2015; e avaliar o impacto do tipo de fenda e da idade na época da palatoplastia nos resultados da fala. Método: Os prontuários de 180 pré-escolares com fenda palatina reparada foram revisados para determinação da porcentagem de crianças com hipernasalidade, emissão nasal, turbulência nasal e distúrbios articulatórios compensatórios. A relação entre o tipo de fenda e a idade no momento da cirurgia de palato, como variáveis independentes, e os resultados de fala também foram avaliados. Resultados: Das crianças, 67,7% e 64,5% apresentavam hipernasalidade moderada/grave e emissão nasal, respectivamente, e 71,1% tinham distúrbios articulatórios compensatórios. A idade no momento do reparo do palato foi significantemente associada aos distúrbios articulatórios compensatórios e também à hipernasalidade moderada/grave. A prevalência de distúrbios articulatórios compensatórios, hipernasalidade significativa, emissão nasal, assim como da turbulência nasal, não foi significantemente diferente nos vários tipos de fenda. Conclusão: Observou-se maior prevalência de diferentes alterações de fala em pré-escolares com fenda palatina reparada em comparação a outros estudos. Isso pode ser parcialmente decorrente do reparo palatino tardio na população estudada. Apesar dos muitos avanços nos programas de tratamento de fenda palatina no Irã, ainda existem muitas crianças que não têm acesso aos cuidados de uma equipe interdisciplinar na primeira infância. Devemos, portanto, tentar aumentar a acessibilidade de serviços de tratamento apropriados e oportunos para todas as crianças iranianas com fenda labiopalatina.

Pharyngeal bulb prosthesis and speech outcome in patients with cleft palate / Obturador faríngeo e resultados de fala em pacientes com fissura palatina

Abstract Introduction: Individuals with cleft palate can present with velopharyngeal dysfunction after primary palatoplasty and require a secondary treatment due to insufficiency. In these cases, the pharyngeal bulb prosthesis can be used temporarily while awaiting secondary surgery. Objective: This study aimed to investigate the outcome of treatment of hypernasality with pharyngeal bulb prosthesis in patients with history of cleft palate presenting with velopharyngeal insufficiency after primary palatal surgery. We hypothesized that the use of the pharyngeal bulb prosthesis is an effective approach to eliminate hypernasality related to velopharyngeal insufficiency in patients with cleft palate. Methods: Thirty speakers of Brazilian Portuguese (15 males and 15 females) with operated cleft palate, ages ranging from 6 to 14 years (mean: 9 years; SD = 1.87 years), participated in the study. All patients were fitted with a pharyngeal bulb prosthesis to manage velopharyngeal insufficiency while they were awaiting corrective surgery to be scheduled. Auditory-perceptual analysis of speech recorded in the conditions with and without pharyngeal bulb prosthesis were obtained from three listeners who rated the presence or absence of hypernasality for this study. Results: Seventy percent of the patients eliminated hypernasality while employing the pharyngeal bulb prosthesis, while 30% still presented with hypernasality. The comparison was statistically significant (p < 0.001). Conclusion: The use of the pharyngeal bulb prosthesis is an effective approach to eliminate hypernasality related to velopharyngeal insufficiency.

Resumo Introdução: Indivíduos com fissura palatina podem apresentar disfunção velofaríngea após a palatoplastia primária e necessitam de um secundário devido à insuficiência velofaríngea. Nesses casos, o obturador faríngeo pode ser usado temporariamente enquanto se aguarda uma cirurgia secundária. Objetivo: Investigar o resultado do tratamento da hipernasalidade com o uso de obturador faríngeo em pacientes com histórico de fissura palatina que apresentam insuficiência velofaríngea após a palatoplastia primária. Nossa hipótese é que o uso do obturador faríngeo seja uma abordagem eficaz para eliminar a hipernasalidade relacionada à insuficiência velofaríngea em pacientes com fissura palatina Método: Participaram do estudo 30 indivíduos falantes do Português Brasileiro (15 homens e 15 mulheres) com fissura palatina operada, de 6 a 14 anos de idade (média: 9 anos; DP = 1,87 anos). Todos os pacientes receberam obturador faríngeo para o tratamento da insuficiência velofaríngea, enquanto aguardavam vaga para a cirurgia secundária. A análise perceptivo-auditiva da fala, realizada nas condições com e sem obturador faríngeo, foi realizada por três ouvintes, quanto à presença e ausência da hipernasalidade. Resultados: 70% dos pacientes eliminaram a hipernasalidade de fala com o uso do obturador faríngeo, enquanto 30% não eliminaram. A comparação foi estatisticamente significante (p < 0,001). Conclusão: O uso temporário do obturador faríngeo é uma abordagem efetiva para eliminar a hipernasalidade decorrente da insuficiência velofaríngea.

Normative nasalance scores in Chilean adults / Valores normativos de nasalancia en adultos chilenos

ABSTRACT Purpose The present study is aimed towards determining and comparing normative nasalance scores in Chilean Spanish-speaking adult men and women. Methods 40 women (age range 18 to 35, X = 25.79, SD = 5.83) and 36 men (age range 18 to 35, X = 26.45, SD = 4.08) were invited to participate, all of them without any previous speech therapy, neurological pathologies, intellectual deficits, hearing loss, syndromes, or other diagnosed pathologies that could impact speech production. A study of proper velopharyngeal function was performed, using a perceptual resonance evaluation. Nasalance was determined using a model 6450 Nasometer, during the reading of three standardized speech samples in Spanish: a nasal passage (NP), an oronasal passage (ONP), and an oral passage (OP). Also, the nasalance distance was calculated. Genders were compared using Wilcoxon tests for independent samples. Results The NP presented the highest percentage of nasalance, with 52.13% (± 4.73), followed by the ONP with 25.38% (± 3.7), and finally the OP, which presented the lowest value of 14.15% (± 5.03). Meanwhile, nasalance distance was 37.98% (± 5.32). Finally, no significant differences were observed when comparing the nasalance between genders (p >0.05). Conclusion The nasalance values obtained were similar to those observed for other Spanish speakers. Also, male and women showed similar scores. The results of this study are a contribution to the indirect assessment of velopharyngeal function in Chilean adults.

RESUMEN Objetivo El presente estudio tiene como objetivo determinar y comparar puntajes normativos de nasalancia en hombres y mujeres chilenos de habla hispana. Método Participaron 40 mujeres (rango de edad de 18 a 35, X = 25.79, DE = 5.83) y 36 hombres (rango de edad de 18 a 35, X = 26.45, DE = 4.08), todos sin ningún antecedente de tratamiento fonoaudiológico, patologías neurológicas, déficit intelectual, hipoacusia, síndromes u otras patologías diagnosticadas que podrían afectar la producción del habla. La adecuada función velofaríngea fue determinada en vivo a través de una evaluación perceptual de la resonancia. La nasalancia se determinó utilizando un Nasometer modelo 6450, durante la lectura de tres muestras de habla estandarizadas en español: un párrafo nasal (PN), un párrafo oronasal (PON) y un párrafo oral (PO). Además, se calculó la distancia de nasalancia. La comparación entre ambos sexos fue realizada con el test de Wilcoxon para muestras independientes. Resultados El PN presentó el mayor porcentaje de nasalancia con 52.13% (± 4.73), seguido del PON con 25.38% (± 3.7), y finalmente el PO, que presentó el valor más bajo de 14.15% (± 5.03). En tanto, la distancia de nasalancia fue del 37.98% (± 5.32). Por último, no se observaron diferencias significativas al comparar entre ambos sexos (p> 0.05). Conclusión Los valores de nasalancia obtenidos fueron similares a los observados para otros hispanohablantes. Además, hombres y mujeres mostraron puntuaciones similares. Los resultados de este estudio son una contribución a la evaluación indirecta de la función velofaríngea en adultos chilenos.

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.

Can a pharyngeal bulb prosthesis eliminate hypernasal speech in individuals with hypodynamic velopharynx?

ABSTRACT Purpose: to investigate the effectiveness of a pharyngeal bulb prosthesis to eliminate hypernasality in patients with operated cleft palate presenting with diagnosis of hypodynamic velopharynx. Methods: twenty patients with cleft palate, ages 11-40 years, presenting hypodynamic velopharynx participated in the study. Patients had their speech audio recorded twice, with and without prosthesis, simultaneously with nasometry. Three speech-pathologists rated the presence and absence of hypernasality. Perceptual and nasometric data without and with prosthesis were compared, using the McNemar Test (p<0.05). Results: three (15%) patients presented hypernasality without prosthesis and normal resonance with prosthesis, 3 (15%), normal resonance without prosthesis and hypernasality with prosthesis, 9 (45%), hypernasality without and with prosthesis, and 5 (25%), normal resonance in both conditions. Nasometry (≤27% cut off): 1 (5%), presented scores >27% without prosthesis and <27% with prosthesis, 2 (10%), scores <27% without prosthesis and >27% with prosthesis, 17 (85%), scores >27% in both conditions, and 1(5%), scores <27% in both conditions. The comparisons between the results were not significant (p=1.000). Conclusion: the pharyngeal bulb prosthesis alone is insufficient to eliminate hypernasality of patients presented with hypodynamic velopharynx. To this purpose, the combination between the prosthesis and speech therapy is required.

Role of Speech Aid Prosthesis as Diagnostic and Therapeutic Aid for Velopharyngeal Insufficiency Defect: A Case Report

ABSTRACT@#Soft palate tumors pose the challenge during reconstructive and rehabilitating procedures. Surgical resection of these tumors leads to velopharyngeal insufficiency (VPI). The primary effects of VPI are hypernasality and air-flow escape, while the secondary effects are abnormalities in speech articulation. Surgical revision along with speech therapy is a common approach to the treatment of VPI. Prosthetic management by means of speech aid prosthesis helps to reduce resonance, nasal emission and consonants errors. This clinical report describes the different stages of rehabilitation of velopharyngeal insufficiency defect following resection of malignant melanoma of left posterior alveolar ridge and soft palate. The speech aid prosthesis helped to rehabilitate the velopharyngeal insufficiency defect and aided in the diagnosis of extent of speech function improvement by perceptual and objective methods.

Evaluación perceptual de la insuficiencia velofaríngea en personas con fisura del paladar: una revisión integradora de literatura / Perceptual evaluation of velopharyngeal insufficiency in people with cleft palate: an integrative literature review

La insuficiencia velofaríngea (IVF) secundaria de fisura del paladar corresponde al cierre incompleto del mecanismo velofaríngeo durante el habla, debido a una falta de tejido en el paladar blando o las paredes de la faringe, lo cual genera una resonancia hipernasal y una emisión nasal de aire en los sonidos orales. Al respecto, en la literatura existen diversas propuestas para la evaluación perceptual de la IVF. Por esto, el objetivo del presente estudio es describir la evaluación perceptiva auditiva de la insuficiencia velofaríngea, mediante una revisión integradora de literatura. Para ello, en mayo de 2020 las bases de datos electrónicas PUBMED, LILACS, SciELO y Cochrane, fueron consultadas utilizando las palabras claves en inglés: "Velopharyngeal Sphincter", "Velopharyngeal Insufficiency", "Cleft Palate", "Speech Intelligibility", "Speech Production Measurement", "Speech Articulation Tests" y "Speech-Language Pathology" y sus respectivos equivalentes en portugués y español. Se seleccionaron artículos originales relacionados al tema, y se creó un protocolo específico para la extracción de los datos. En total se encontraron 2.385 artículos. De ellos, 2.354 fueron excluidos por el título, 13 por el resumen y 3 luego de la lectura del texto completo. Finalmente, a partir de la metodología desarrollada, en esta revisión fueron utilizados 33 artículos. A partir de la revisión realizada se concluye que los parámetros más utilizados en la evaluación son la hipernasalidad, la emisión nasal y la articulación compensatoria asociada a IVF. Estos parámetros son evaluados principalmente en oraciones, habla espontánea y palabras, por un fonoaudiólogo experto, en vivo y mediante grabaciones de audio.

Secondary Velopharyngeal insufficiency (VPI) to cleft palate corresponds to the incomplete closure of the velopharyngeal mechanism during speech, due to lack of tissue in the soft palate or the walls of the pharynx, which generates a hypernasal resonance and nasal air emission in oral sounds. In this regard, there are various proposals in the literature for the perceptual evaluation of VPI. For this reason, the objective of the present study is to describe the auditory perceptual evaluation of velopharyngeal insufficiency, through an integrative literature review. To this end, in May 2020 the electronic databases PUBMED, LILACS, SciELO and Cochrane were consulted using the key words in English: "Velopharyngeal Sphincter", "Velopharyngeal Insufficiency", "Cleft Palate", "Speech Intelligibility", "Speech Production Measurement", "Speech Articulation Tests" and "Speech-Language Pathology", and their equivalent properties in Portuguese and Spanish. Original articles related to the topic were selected, and a specific protocol for data extraction was created. In total, 2,385 articles were found. Of these, 2,354 were excluded due to the title, 13 due to the abstract and 3 after reading the full text. Finally, based on the methodology developed, 33 articles were used in this review. From the review carried out, it is concluded that the parameters most used in the evaluation are hypernasality, nasal emission and the compensatory joint associated with IVF. These parameters are evaluated mainly in sentences, spontaneous speech and words, by an expert speech therapist, live and through audio recordings.

Intensive therapy for speech rehabilitation of a patient with cleft lip and palate: a case report / Terapia intensiva para a reabilitação da fala em paciente com fissura labiopalatina: relato de caso

ABSTRACT Intensive therapy is an alternative to accelerate the therapeutic process of individuals with cleft lip and palate. The purpose of this study is to describe an intensive speech therapy program and compare the results before and after the program on a child with previously operated right unilateral cleft lip and palate and velopharyngeal insufficiency, using a speech bulb. Sixty therapy sessions were carried out over a 4-week period. Before and after, anamnesis, speech assessment and evaluation of the velopharyngeal function with nasofibroscopy, were performed. The patient presented with adequate resonance and speech intelligibility, reduction of obligatory disorders and compensatory articulations, after intensive therapy with the speech bulb and reduction of velopharyngeal gap, after intensive therapy with and without the speech bulb. Progress was achieved with the intensive speech therapy.

RESUMO A terapia intensiva é uma alternativa para acelerar o processo terapêutico de indivíduos com fissura labiopalatina. O objetivo desse estudo foi descrever, aplicar um programa de terapia intensiva e comparar a evolução antes e após o programa de fonoterapia de uma criança com fissura transforame incisivo unilateral direita operada e insuficiência velofaríngea em uso de prótese de palato obturadora. Foram realizadas 60 sessões de terapia, durante 4 semanas. Antes e após, aplicou-se anamnese, avaliação da fala e nasofibroscopia. Como resultado, a paciente apresentou adequação da ressonância e da inteligibilidade de fala, diminuição dos distúrbios obrigatórios e das articulações compensatórias após terapia intensiva com prótese de palato obturadora; e redução do gap velofaríngeo após a terapia intensiva com e sem o uso da prótese. Concluiu-se que a fonoterapia intensiva proporcionou evolução do caso.

Cephalometric predictors of hypernasality and nasal air emission

Abstract During times of increasingly recognized importance of interprofessional practices, professionals in Medicine, Dentistry, and Speech Pathology areas cooperate to optimize treatment of velopharyngeal dysfunction (VPD), after primary palatoplasty for correction of cleft palate. Objective Our study aims to compare velar length, velar thickness, and depth of the nasopharynx of patients with unilateral cleft lip and palate (UCLP) with the presence, or absence, of hypernasality and nasal air emission; and to verify if the depth:length ratio, between nasopharynx and velum, would be predictive of consistent hypernasality and nasal air emission (speech signs of VPD). Methodology Cephalometric radiographs and outcome of speech assessment were obtained from 429 individuals, between 6 and 9 years of age, with repaired unilateral cleft lip and palate. Velar length, velar thickness, depth of the nasopharynx, depth:length ratio, scores of hypernasality, and scores of nasal air emission were studied and compared; grouping the radiographs according to presence or absence of hypernasality and nasal air emission. Results For the group with speech signs of velopharyngeal dysfunction (those with consistent hypernasality and nasal air emission), the velums were shorter and thinner; the nasopharynx was deeper and the depth:length ratio was larger than the group without hypernasality and nasal air emission. Velar length was significantly shorter in individuals with consistent hypernasality and nasal air emission (p<0.001) and with history of palatal fistula (p=0.032). Depth of nasopharynx was significantly greater in individuals with consistent hypernasality and nasal air emission (p<0.001). Depthlength ratio was significantly larger in individuals with consistent hypernasality and nasal air emission (p<0.001). A depth:length ratio larger than 0.93 was always associated with speech signs of VPD. Conclusion Estimated with cephalometric radiographs, a depth:length ratio greater than 0.93, between the nasopharyngeal space and the velum, was 100% accurate in predicting hypernasality and nasal air emission after primary repair of unilateral cleft lip and palate.

A comparison result of primary cleft palate repair by various techniques / Монголын Анагаах Ухаан

Background@#The main purpose of primary cleft palate repair is to reconstruct anatomical structure with minimal impairment of maxillary growth and normalize velopharyngeal function and feeding process. One of the most common complications after the primary cleft palate repair is velopharyngeal insufficiency, which leads to the subsequent surgery. The velopharyngeal function assessment characterizes speech development in children. Researches noted that velopharyngeal insufficiency causes in 5-86% after primary cleft palate repair. Therefore, it is essential to choose an adequate primary surgical method for each particular type of cleft palate.@*Objective@#To compare velopharyngeal function using nasopharyngoscopy after primary CP repair@*Materials and Methods@#The patients who with congenital cleft palate and, underwent primary cleft palate repair in the Department of Maxillo-facial surgery of the National Centre for Maternal and Child Health and had velopharyngeal function assessment were recruited to the study. Patients with wound dehiscence and oronasal fistula postoperatively were excluded from the study. </br> Cleft palate was classified according to the Veau system and Golding-Kushner scale of nasopharyngoscopy was used to assess patient’s velopharyngeal function in order to associate with cleft types and the primary palatoplasty techniques. Pearson’s chi-squared analysis and Fisher exact test were used for statistical analysis. @*Results@#A total of 335 patients were included in the study. The mean age at primary palate repair was 22.9±13.6 months. There were 56, 42, 177, and 60 patients with Veau-I type, Veau-II type, Veau-III type and Veau- IV type respectively, whereas for primary palatoplasty 65 patients underwent Furlow technique, 148 patients – Mongolian technique, 108 patients – Two flap technique, 34 patients – Von Langenbeck technique.</br> Nasopharyngoscopy assessment of adequate velopharyngeal function was as followed as by “Furlow” technique in 89.4% cases, ”Mongolian” technique in 62.2% cases but by “Two flap” technique only in 48.1% and Von Langenbeck technique in 47.1% cases. @*Conclusion@#The Furlow and Mongolian techniques were superior for maintaining velopharyngeal function after primary palatoplasty.

Clinical study on obstructive sleep apnea following pharyngeal flap surgery / 华西口腔医学杂志

OBJECTIVES@#This study aims to investigate the incidence and severity of obstructive sleep apnea (OSA) in cleft patients with velopharyngeal insufficiency (VPI) after pharyngeal flap surgery (PFS) and explore the influence of operation age.@*METHODS@#A retrospective study was conducted in 82 cleft patients after PFS. The patients were divided into two groups according to their age at the time of surgery. The incidence and severity of OSA were assessed at least 1.2 years (mean 6.0 years) postoperatively by polysomnography (PSG).@*RESULTS@#The incidence rates of OSA were 20% in the adult group and 31% in the child group. No significant difference was found between the two groups (@*CONCLUSIONS@#Some patients still have OSA average of 6.0 years after PFS, and operation ageis unrelated to the incidence and severity of OSA.

Advances in classification and reconstruction of palatal fistula after cleft palate operation / 口腔疾病防治

@#Postoperative fistulae are one of the most significant complications of cleft palate repair. They usually has an adverse effect on patients’ oral hygiene, speech and even mental health. There has been a wide range of rates of fistula occurrence, from 0.8%-60%, with the classification and definition of fistulae differing from one author to the next. In this paper, the definition and classification of palatal fistulae and their reconstruction method are reviewed. At present, there is a lack of a consistent definition of palatal fistulae and a classification that can fully reflect the characteristics of palatal fistula. Adjacent flap is mainly used for repairing small fistulae with an adequate amount of surrounding tissue; anteriorly based dorsal tongue flaps are a safe and reliable method for large fistulae; free flap is beneficial for refractory and complicated palatal fistulae that are difficult to repair by the local and pedicle flap; and different synthetic materials are used in multilayer repair of fistulae; among them, composite polymer membrane is highly biocompatible, promoting cell attachment and proliferation in animal models, but its security in the human body needs further research.

Research progress on autologous fat transplantation in the treatment of velopharyngeal insufficiency / 口腔疾病防治

@#Autologous fat transplantation in the treatment of velopharyngeal insufficiency has the advantages of good histocompatibility, small local trauma, few complications, reversible operation and simple postoperative nursing, which can effectively increase the velopharyngeal closure area. If the clinical effect is poor, other surgical methods can be used at any time for replacement. Although there are many advantages in the treatment of velopharyngeal insufficiency with autologous fat transplantation, there are still some problems in the selection of indication, donor site, injection dose, recipient site, follow-up evaluation, complications and prevention and treatment. Current research shows that autologous fat transplantation is mainly used in patients with mild or moderate velopharyngeal insufficiency, but with the improvement of fat acquisition and treatment techniques, the indications for autologous fat transplantation continue to expand, and autologous fat transplantation combined with palatoplasty or pharyngoplasty has been proposed for the treatment of severe velopharyngeal insufficiency. However, there are complications, such as fat absorption and obstructive sleep apnea syndrome. In addition, the application of autologous fat transplantation in severe VPI patients and how to improve the long-term stability of autologous fat transplantation need further study.

Assessment of velopharyngeal insufficiency and oronasal fistula after primary surgery of cleft palate

Background:Cleft palates are the most common congenital craniofacial anomalies in children, and their treatment is challenging in terms of outcomes. The objective of the study was to determine the incidence of velopharyngeal insufficiency (VPI), and of the oronasal fistula after a veloplasty. Methods:By a retrospective study, over a period of 2 years, going from January 2017 to December 2018, carried out in the department of ENT and head and neck surgery of the August 20 hospital in Casablanca, Morocco. The inclusion criteria were all patients operated on for a cleft palate. The main results were the incidence of VPI, and of the oronasal fistula after a primary repair of the palate.Results:Out of a total of 21 cases, the average age was 4 years, and the sex ratio was 0.61, the average postoperative follow-up duration was 1 year and 9 months. VPI was found in 13 patients (62%), it was mild in 3 patients (14%), moderate in 6 patients (28%), and severe in 4 patients (19%), the frequency of VPI increased significantly with increasing age (p=0.05). The oronasal fistula was found in 5 (23.8%) patients, this fistula was more frequent when the patient benefited from the operation at an early age.Conclusions:Age is the most important factor in the management of cleftpalates

Palatoplastia primária pela técnica de Von Langenbeck: experiência e resultados morfológicos obtidos em 278 casos operados / Primary palatoplasty using the von Langenbeck technique: surgical experience and aesthetic results of 278 cases

Introdução: A palatoplastia com elevação de retalhos mucoperiostais bipediculados pela técnica de Von Langenbeck associada a veloplastia intravelar é técnica mais utilizadas na atualidade apresentando na literatura baixa taxa de fístula oronasal e de insuficiência velofaríngea. O objetivo é apresentar a experiência acumulada do autor e avaliar a incidência de fístula oronasal após 278 casos de palatoplastia primária, pela técnica de Von Langenbeck associada a veloplastia intravelar. Métodos: Estudo retrospectivo de 278 prontuários de pacientes submetidos à palatoplastia primária no Centro de Tratamento de Malformações Craniofaciais Mário Covas - Hospital Guilherme Álvaro - Santos/SP, entre de maio de 2010 a maio de 2018. Resultados: 278 procedimentos de palatoplastia primária pela técnica relatada, 225 (80,9%) em duas etapas cirúrgicas e 53 (19,1%) em única etapa. Masculino 182 (65,5%) e feminino 96 (34,5%). Fissuras labiopalatais esquerda e bilaterais (26,3% e 27%, respetivamente). As fissuras palatais completas corresponderam a 37,4% e a fissura labiopalatal direita com 7,6%. 61 pacientes apresentaram fístula oronasal (21,94%) observando-se uma diminuição progressiva da incidência em cada período. Conclusão: A palatoplastia primária pela técnica de Von Langenbeck associada à veloplastia intravelar é uma técnica reprodutível em uma ou duas etapas cirúrgicas e pode ser considerada segura quando alcançada uma adequada curva de aprendizado apresentando um índice de complicações acorde com a literatura mundial.

Introduction: Palatoplasty with elevated bilateral mucoperiosteal flaps using the von Langenbeck technique associated with intravelar veloplasty is a common procedure with low rates of oronasal fistula (ONF) and velopharyngeal insufficiency. The objective is to present the author's surgical experience and the incidence of ONF among 278 patients who underwent primary palatoplasty using the von Langenbeck technique associated with intravelar veloplasty. Methods: This retrospective study analyzed the medical records of 278 patients who underwent primary palatoplasty at the Mário Covas Treatment Center for Craniofacial Malformations of the Guilherme Álvaro Hospital located in the municipality of Santos, São Paulo, Brazil, between May 2010 and May 2018. Results: A total of 278 primary palatoplasty procedures were performed; of them, 225 (80.9%) were performed in two surgical stages and 53 (19.1%) in one surgical stage. The study population included 182 men (65.5%) and 96 women (34.5%). The prevalence of left and bilateral cleft lip and palate was 26.3% and 27%, respectively, and the prevalence of bilateral cleft palate, and right cleft lip and palate was 37.4% and 7.6%, respectively. Sixty-one patients had ONF (21.94%), the incidence of which decreased progressively throughout the study period. Conclusion: Primary palatoplasty, using the von Langenbeck technique associated with intravelar veloplasty, is reproducible when performed in one or two surgical stages, and considered safe when the learning curve is reached with a complication rate similar to those in the literature.