Velopharyngeal Muscle Morphology in Children With Unrepaired Submucous Cleft Palate: An Imaging Study.

OBJECTIVE: To identify quantitative and qualitative differences in the velopharyngeal musculature and surrounding structures between children with submucous cleft palate (SMCP) and velopharyngeal insufficiency (VPI) and noncleft controls with normal anatomy and normal speech. METHODS: Magnetic resonance imaging was used to evaluate the velopharyngeal mechanism in 20 children between 4 and 9 years of age; 5 with unrepaired SMCP and VPI. Quantitative and qualitative measures of the velum and levator veli palatini in participants with symptomatic SMCP were compared to noncleft controls with normal velopharyngeal anatomy and normal speech. RESULTS: Analysis of covariance revealed that children with symptomatic SMCP demonstrated increased velar genu angle (15.6°, P = .004), decreased α angle (13.2°, P = .37), and longer (5.1 mm, P = .32) and thinner (4 mm, P = .005) levator veli palatini muscles compared to noncleft controls. Qualitative comparisons revealed discontinuity of the levator muscle through the velar midline and absence of a musculus uvulae in children with symptomatic SMCP compared to noncleft controls. CONCLUSIONS: The levator veli palatini muscle is longer, thinner, and discontinuous through the velar midline, and the musculus uvulae is absent in children with SMCP and VPI compared to noncleft controls. The overall velar configuration in children with SMCP and VPI is disadvantageous for achieving adequate velopharyngeal closure necessary for nonnasal speech compared to noncleft controls. These findings add to the body of literature documenting levator muscle, musculus uvulae, and velar and craniometric parameters in children with SMCP.

Language Development in Children With Cleft Palate With or Without Cleft Lip Adopted From Non-English-Speaking Countries.

PURPOSE: The purpose of this study was to determine whether language skills differed between children with cleft palate or cleft lip and palate (CP±CL) who were adopted into an English-speaking home from a non-English-speaking country (late English exposure [LE]) and children with CP±CL raised from birth in an English-speaking home (early English exposure [EE]). METHOD: Children (51 LE, 67 EE), ages 3;0 (years;months) to 9;0, completed the Clinical Evaluation of Language Fundamentals (CELF), Preschool Second Edition or Fourth Edition. Linear regression analysis was used to assess the impact of age of adoption and time in an English-speaking home on language skills, as measured by the CELF-P2 and CELF-4. RESULTS: Children with CP±CL who were adopted scored less well on all language indices, with mean adjusted differences between LE and EE children ranging from 0.4 to 0.7 SD on the CELF index scales. Only 53% of the EE children and 57% of the LE children obtained scores above 90 on all indices. For LE children, younger age at adoption was associated with better language skills. CONCLUSION: CP±CL increases risk for language delay, with the highest risk for LE children. LE children with CP±CL should receive language services soon after adoption.

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.