Efficacy of continuous positive airway pressure for treatment of hypernasality.

OBJECTIVE: To determine whether speech hypernasality in subjects born with cleft palate can be reduced by graded velopharyngeal resistance training against continuous positive airway pressure (CPAP). DESIGN: Pretreatment versus immediate posttreatment comparison study. SETTING: Eight university and hospital speech clinics. PATIENTS: Forty-three subjects born with cleft palate, aged 3 years 10 months to 23 years 8 months, diagnosed with speech hypernasality. INTERVENTION: Eight weeks of 6 days per week in-home speech exercise sessions, increasing from 10 to 24 minutes, speaking against transnasal CPAP increasing from 4 to 8.5 cm H(2)0. MAIN OUTCOME MEASURES Pretreatment to immediate posttherapy change in perceptual nasality score based on blinded comparisons of subjects' speech samples to standard reference samples by six expert clinician-investigators. RESULTS: Participating clinical centers treated from two to nine eligible subjects, and results differed significantly across centers (interaction p =.004). Overall, there was statistically significant reduction in mean nasality score after 8 weeks of CPAP therapy, whether weighted equally across patients (mean reduction = 0.20 units on a scale of 1.0 to 7.0, p =.016) or across clinical centers (mean = 0.19, p =.046). This change was about one-sixth the maximum possible reduction from pretreatment. Nine patients showed reductions of at least half the maximum possible, but hypernasality of eight patients increased at least 30% above pretreatment level. Most improvement was seen during the second month when therapy was more intense (p =.045 for nonlinearity). No interactions with age or sex were detected. CONCLUSION: Patients receiving 8 weeks of velopharyngeal CPAP resistance training showed a net overall reduction in speech hypernasality, although response was quite variable across patients and clinical centers. The net reduction in hypernasality is not readily explainable by random variability, subject maturation, placebo effect, or regression to the mean. CPAP appears capable of substantially reducing speech hypernasality for some subjects with cleft palate.

Diagnostic value of articulation tests with individuals having clefts.

Articulation testing provides a structure for evaluating children with cleft or velopharyngeal incompetency in a specific manner so that they can be compared with normative data and later to themselves. Results from an articulation test should always be compared to the precept of what is heard in conversation, specifically on articulation, nasality, and velopharyngeal competency. Analysis of an articulation test provides data for the speech clinician to develop a therapy program which is realistic and structured. Articulation tests also help clinicians evaluate the child's progress.

A proposal for standardization of speech and hearing evaluations to assess velopharyngeal function.

The article comprises the proposal made by the Cleft Palate Committee of IALP to standardize the parameters of the speech and hearing evaluation in individuals with cleft palate/velopharyngeal incompetence (CP/VPI). The suggested parameters are the following: nasal resonance, nasal escape, articulation and its disorders, facial grimacing, speech intelligibility, patient teachability, expressive language and voice. The authors recommend a five-point scale description system, which can be used also for assessment of hearing, velopharyngeal competence and other attributes of the CP/VPI individual. The most important diagnostic procedures are: X-ray (video/cinefluoroscopy), nasopharyngoscopy, nasometry; in dubious cases it is also fundamental to clarify the etiology with electrophysiological methods. The utilization of this proposal might contribute to a more accurate diagnosis and a more effective treatment on an international basis.

Identification of children with and without cleft palate from tape-recorded samples of early vocalizations and speech.

Thirty judges (5 speech pathologists, 10 mothers of children with cleft palate, and 15 mothers of noncleft children) listened to 90 tape-recorded samples of early vocalizations/speech obtained from noncleft babies and babies with cleft palate. Each sample was classified by the judges as normal or abnormal. As a group, the speech pathologists classified only 60% of the cleft samples as abnormal and 59% of the normal samples as normal. The cleft and noncleft mother groups, on the other hand, classified 37% and 25% of the cleft samples as abnormal and 59% and 73% of the normal samples as normal. Poor interjudge agreement was evident within and across the three groups of judges. The poor reliability demonstrated by the speech pathologists in identifying babies with unrepaired clefts appeared related more to a difference in interpretation of the perceptual data than an inability to hear salient information.

Long-term speech results of cleft palate patients with primary palatoplasty.

This investigation examined the influence of cleft type, type of surgery, age at surgery, and gender on speech proficiency of 204 patients with cleft palate who required only primary palatoplasty. Speech measures were obtained for each subject from at least three annual examinations between the ages of 4 and 16 years. Neither age at surgery nor type of surgery were discriminating factors. The less extensive cleft type, i.e., soft palate only, was associated with greater rates of change in the performance variables than were the other three cleft types. Females showed greater rate changes than males.

Correspondence between nasalance scores and listener judgments of hypernasality and hyponasality.

The relationship between nasalance scores and perceptual judgments of hypernasality and hyponasality was examined for 74 subjects (51 with cleft palate and 23 noncleft controls). Twenty-nine of the 51 subjects with cleft palate had received pharyngeal flap surgery. Predictive analyses were performed to assess the sensitivity, specificity, and efficiency of the Nasometer as a screening instrument. The overall relationship between perceptual judgments of hypernasality and nasalance scores was good for the nonflap subjects when a nasalance cutoff score of 26 was used. A sensitivity coefficient of 0.87 and a specificity coefficient of 0.93 were obtained. Ninety-one percent of the nasometry-based classifications accurately reflected listener judgments of hypernasality. The correspondence between nasalance scores and clinical judgments of hyponasality was also good for the nonflap subjects when a nasalance cutoff score of 50 was used. Ninety-one percent of these classifications were consistent with the listener judgments. Efficiency of nasometry was poorer for the flap subjects.

Communication status following laryngectomy: the Iowa experience 1984-1987.

Data regarding treatment and outcome for a consecutive series of 73 total laryngectomy patients were collected from clinical records with a follow-up period of 30 to 78 months postoperatively. Notable findings were that 27% were women; 75% reported hoarseness or a voice change as an early symptom; and 22% reported combined heavy use of both cigarettes and alcohol. Of the 73 patients, 38 (52%) died during the follow-up period; 18 of the 38 died within 1 year postoperatively. Thirty-nine (53%) of the 73 had received a surgical tracheoesophageal fistula (TEF) for voice restoration, as either a primary or a secondary procedure. Of the 39, 75% were using the TEF at last examination, with no failures attributed to sphincter spasm. Of the total group, the primary communication modality was reported to be use of a TEF by 44% and use of an electrolarynx by 50%. Limitations of the study and directions for future investigations are discussed.

Long-term speech results of cleft palate speakers with marginal velopharyngeal competence.

The purposes of this study were to (1) examine the long-term speech status of patients judged to exhibit marginal velopharyngeal competence at 6 years of age and (2) determine whether speech performance data obtained at age 6 could be used to discriminate patients with marginal velopharyngeal competence who eventually demonstrate velopharyngeal incompetence from those who do not. Longitudinal speech performance data were retrieved for 48 subjects and examined descriptively for the total group. Data obtained at the subjects' last evaluation (adolescence) were then used to reassign these subjects into one of three classification groups for estimating velopharyngeal status (competent, marginal, incompetent) on the basis of the clinical ratings of velopharyngeal competence assigned at the time of their last examination in adolescence. Differences in measures of articulation proficiency and hypernasality among the three groups were examined at age 6 using an analysis of variance. A stepwise discriminate analysis was also performed to determine whether the speech data obtained at age 6 could be used to discriminate the three adolescent classification groups. The ANOVA revealed no significant differences among the classification groups in type of articulation errors. Differences in articulation test scores and severity ratings of articulation defectiveness and nasality in connected speech were evident among the groups. The discriminate analysis revealed that the groups could be separated, in part, on the basis of two variables: the severity ratings of articulation defectiveness and nasality.

Velar-pharyngeal status in cleft palate patients with expected adenoidal involution.

This study was designed to provide information about whether cleft palate patients with hypertrophied adenoids maintain velar-pharyngeal contact during the time of expected adenoidal atrophy. Thirty-nine subjects were selected from a large longitudinal study on the basis of availability of lateral still x-ray films taken in series from 5 to 16 years of age. Ratings of velar-pharyngeal contact and ratings of adenoid size were obtained from the films. The obtained data indicated the expected decrease in adenoid size but also, for the group, maintenance of velar-pharyngeal contact. However, three of the 39 subjects were judged to show loss of such contact during the period of study, and an additional four had surgery for velopharyngeal incompetence after the completion of the study. All seven appeared to show significant deterioration of velopharyngeal status in middle or late adolescence. Implications of these findings are discussed.

Speech results of the Zürich approach in the treatment of unilateral cleft lip and palate.

The purpose of this study was to describe perceptually the speech articulation, voice quality, and velopharyngeal competency of subjects with complete unilateral cleft lip and palate treated by the Zürich approach. The mean age of the 37 subjects was 10.5 years. Although only one subject had had secondary palatal management, no subject was rated as exhibiting a severe articulation or nasality problem. Subjects were rated as exhibiting adequate to marginal velopharyngeal competency 94.5 percent of the time, and the incidence of compensatory articulation errors was low. In comparison with other studies that evaluated the two-stage palatal repair, the Zürich approach appears to give the better results. The type of initial soft palate repair is probably the significant factor which contributes to the better speech of these subjects.

Assessment of velopharyngeal competence: a long-term process.

This study compared longitudinally perceptual ratings of articulation defectiveness, nasality, and velopharyngeal competency in 13 subjects who required secondary palatal management after age 10 with a second group. Perceptual data when examined longitudinally did not adequately discriminate between subjects who at one time achieved velopharyngeal closure but who ultimately required secondary management and those patients who needed no further treatment. A decrease in articulation scores and an increase in severity of nasality and articulation defectiveness over time indicate that patients are at risk for secondary management. Evaluation of lateral x-rays indicated that those in the group that required secondary operations demonstrated more variability in velopharyngeal closure than those in the comparison group, who required no secondary operations and that adenoidal involution did not appear to be a significant factor.

Experience with surgical management of velopharyngeal incompetence.

Accurate mapping of the defect of velopharyngeal closure in patients with velopharyngeal incompetence is paramount to the planning of an operative procedure that will have a successful outcome. Nasoendoscopy and videonasoendoscopy are valuable tools for examination of the abnormal pattern of velopharyngeal movement in patients with velopharyngeal incompetence. On the basis of the knowledge of the observed defect in velopharyngeal closure for the particular patient, a pharyngeal flap operation is planned. The flap width, level of placement of the flap base, and control of the lateral port size vary to suit each individual velopharyngeal closure defect. Postoperative speech results in 86 patients are reported.

A study of cleft palate speakers with marginal velopharyngeal competence.

This study was designed as a partial test of a previously hypothesized model for a subgroup of cleft speakers who show marginal velopharyngeal competence during speech. Specifically, speakers in the model were hypothesized to show minimal but consistent nasalization of speech by several criteria. Fifty-two subjects were selected because they met one of the criteria for the model, lateral x-ray films on /s/ that showed touch closure or a small velopharyngeal opening. The subjects were then examined by the other five criteria used for defining the hypothesized model, and were found to meet, in the majority, fewer than three. These findings indicate that lateral x-ray films are not sufficient for identifying this diagnostic subgroup, if it exists. Another possible conclusion is that the model proposed is too simplistic and that cleft palate speakers with marginal velopharyngeal competency typically show more variability in speech performance than was originally implied in the model.

Longitudinal speech performance in patients with cleft palate: comparisons based on secondary management.

Speech performance of three groups of speakers with cleft palate was analyzed at two-year intervals from age 4 years through age 16 years. The three groups consisted of: Group A--individuals who score below 20 percent correct on the Iowa Pressure Articulation Test (IPAT) at 4 years of age and who received secondary surgery by 8 years of age; Group B--individuals who scored below 20 percent correct on the Iowa Pressure Articulation Test at 4 years of age, but did not receive secondary management by 8 years of age; and Group C--individuals who scored above 20 percent correct on the Iowa Pressure Articulation Test and who did not receive secondary surgery by 8 years of age. The results demonstrated that Group A performed better on several measures of speech performance at 16 years of age than either of the other groups. Also, speech performance appeared to become slightly worse around 12 years of age for Group B. This may be interpreted as evidence that this group may have been negatively affected by the physiologic changes associated with puberty. The other two groups did not appear to show this effect. The results of this study emphasize the need for careful research regarding patients who, in spite of early poor speech performance, are not considered candidates for early secondary management.

Effectiveness of intensive articulation therapy for children with cleft palate.

The effectiveness of a 6-week summer residential speech program was evaluated for 13 children with cleft lip and palate or cleft palate only. All children received a pretherapy evaluation followed by 4 hours of articulation therapy daily, for 26 days. Speech status was assessed immediately following the intensive therapy program and again on a 9-month follow-up. The findings of this study indicated that while the subjects significantly improved their articulation performance during the program, their progress was much slower than expected. There was no significant difference between the articulation scores obtained immediately posttherapy and those obtained during the 9-month follow-up examination, even though most subjects had received speech therapy during the year through their public school system. Only 3 of the 13 subjects demonstrated better articulation skills during the follow-up examination.

Longitudinal evaluation of articulation and velopharyngeal competence of patients with pharyngeal flaps.

In this study, 129 patients with cleft palate who had pharyngeal flaps were evaluated longitudinally. Articulation scores improved approximately 15 percent following surgery, and by age 16 the majority of subjects achieved velopharyngeal competence and 90 percent correct articulation. The findings also demonstrated that the risk of requiring secondary management increased with the severity of the cleft. In addition, a higher percentage of patients who had received a primary Von Langenbeck procedure required secondary management than did patients who had the Wardill primary palatoplasty. Age at time of the pharyngeal flap operation did not emerge as a critical factor in speech outcome.

Reliability of the nasopharyngeal fiberscope (NPF) for assessing velopharyngeal function: analysis by judgment.

The reliability and validity of data about velopharyngeal function obtained with the nasopharyngeal fiberscope was assessed in normal subjects. The experimental design included data reduction procedures that are likely to have clinical utility (clinical ratings). The results indicated that relative velar movement and size of the velopharyngeal port may be reliably and validly estimated using the procedures. However NPF estimates of lateral pharyngeal wall movement were not reliable. Finally, the data indicated that velar movement and size of V-P port were consistent within subjects and tasks across data collection sessions. Data about consistency of lateral wall movement across sessions was inconclusive, however. Additional research involving similar procedures with subjects who have morphologic deficits is indicated.

Pre-school articulation test to assess velopharyngeal competency: normative data.

The purpose of this work was to develop an articulation test which would be discriminating in the determination of velopharyngeal incompetency in young children. From 50 words containing the /p/ and /b/ sounds, normative data for children approximately 3 1/2 years of age were collected. From the responses of these children, 25 words were selected for a base test. Validity of the test is currently being determined.