Cleft palate speech evaluation ain’t easy.

 

Typically in the US, specialists evaluate children born with a cleft lip and/or palate after his or her lip and palate are closed in year one or two. If they find deficient structural elements (e.g., a short soft palate) for producing intelligible speech, they tend to advocate further corrective surgery. When all speech-creating structures are aligned as well as possible, then children have the best chance of developing normal speech. Speech therapists sometimes work with children as soon as they start talking. 

I’ve heavily-condensed this recent article by B. Prathanee, an associate professor of Speech and Language. It shows how complex the evaluation can be. The article is available here.

Cleft Palate – .

“Communication problems are common in individuals with . Successful surgery in early months of life and an effective multidisciplinary approach in later years are important for minimizing the associated problems, however, most people with still have communication stigmas associated with cleft lip and/or palate. Communication disorders in cleft palate are typical, complicated, and present significant challenges including:

  • Delayed speech and language development
  • Articulation disorders: 
  • Voice disorders from laryngeal hyperfunction in an attempt to compensate for acoustic effects of velopharyngeal dysfunction or compensatory articulation of glottal stops
  • Deviant resonance and nasal airflow from velopharyngeal insufficiency (VPI) . . . .

There are several protocols and methods that exist for evaluating speech and language disorders in cleft palate. These include perceptual speech assessments, intraoral examination, language assessments, articulation tests, universal parameter tests for standard speech reporting , acoustic analysis (e.g., spectrography, the oral-nasal acoustic ratio), aerodynamic measurements, observation of structure movement (e.g., nasopharyngoscopy, videofluoroscpoy, electromyography). This article aims to summarize the evaluation of speech and language disorders in individuals with cleft lip and/or palate.

Oral peripheral examination

Oral peripheral examination aims to identify features affecting speech and language problems in cleft palate (Witzel 1995, Peterson-Falzone et al. 2010, Kummer 2008). The oral peripheral examination includes examination of the nose, lips, teeth, malocclusion, maxilla, mandible, tongue (ankyloglossia or short frenulum), hard palate, soft palate, pharynx, larynx and related function.

Evaluation of language

Various and broad language assessment tools have been in use for several years in many languages. It is important to keep in mind that these tools should have validity and reliability. . . For infants and toddlers from age for 0-18 months, assessment of early communication skills and language development focuses on 3 major areas of communicative behavior: parent-child interaction, early social communication skills, and receptive and expressive language skills . . .

Evaluation of speech disorders

Systems for the assessment of cleft speech disorders have been developed to elicit cleft-type speech characteristics and have been available for use for many years. Both perceptual and instrumental assessments exist and are used for reporting speech outcomes. . . . 

Overall, most cleft palate speech assessments generally contain universal speech parameters including:

  1. Hypernasality
  2. Hyponasality
  3. Audible nasal air emission and/or nasal turbulence
  4. Consonant production errors
  5. Voice disorder
  6. Speech intelligibility/ understandability/ acceptability

. . .

For global assessment, the parents’ and layman’s evaluation should also be included because children with cleft have to function in a social environment that is often highly competitive (Witt et al. 1996). The perceptual speech assessment result, as judged by a parent and or layman group (naive untrained persons), is crucial as it reflects the patient’s social function.

. . .

Evaluation of velopharyngeal insufficiency (VPI)

VPI is the inability to completely close the velopharyngeal part of the oral cavity during speech. The resultant leakage of air into the nasal cavity during speech can cause hypernasal vocal resonance and nasal emission/turbulence. Estimation of the prevalence of hypernasality/ VPI ranges from 5-67% (Morris 1973, Spriestersbach et al. 1973, Enderby and Emerson 1995, Peterson-Falzone and Graham 1990) based on cleft types. Although perceptual speech evaluation is subjective, it is still the gold standard and therefore a necessary measurement.

In addition to perceptual speech assessment, adequate measurement of velopharyngeal closure requires direct instrumental measurement in order for further management and intervention to be carried out. Many methods exist for evaluating velopharyngeal function. Each method has inherent strengths and weakness. . .

Nasometry is a technique that provides a nasalance score (the percentage of nasalance score is calculated from nasal acoustic energy divided by nasal acoustic energy plus oral acoustic energy, multiplied by 100). Nasometry is an noninvasive measurement that needs minimal patient cooperation. . . .

Pressure flow technique or aerodynamic assessment provides quantitative measurement of velopharyngeal function and was developed by Warren and Dubois (Warren and Dubois 1964) based on a Theoretical Hydraulic Principle. It is assumed that the area of the velopharyngeal port can be determined if the differential pressure across the orifice is measured simultaneously with rate of airflow through it. . . .

The nasality severity index (NSI) is an objective measurement of hypernasality based on a multiparameter approach. It was recently developed by Van Lierde et al. . . .

Component rhinomanometry is a technique for partitioning nasal airway resistance into its nasal cavity and velopharyngeal components. It helps to determine nasal airway potency for functional management of the cleft nose and for management of hyponasality. . .

Nasopharyngoscopy is a technique for direct velopharyngeal functional examination that allows observation of the velopharyngeal port during speech using an endoscope. Movements of the soft palate, posterior, lateral pharyngeal walls, and patterns of velopharyngeal closure are seen. . . .

Lateral cephalometric radiography is a standardization of lateral head radiography that allows development of quantitative craniometry. It allows quantifiable assessment of the skeletal framework and the associated soft-tissue structures of the velopharyngeal mechanism. . . .

Videofluoroscopy is an effective means for evaluating of the movement of the velopharyngeal mechanism during real-time speech. Three views (lateral, frontal, and the cranial base) can be investigated, providing information on the a three-dimentional structure that operates as a sphincter. It provides the best information regarding the dynamic function of velar, and pharyngeal wall movement. . . .  Videofluoroscopy provides helpful dynamic visualization but involves radiation exposure.

Diagram of child beginning cleft lip speech evaluation.

Child begins cleft lip speech evaluation.

Magnatic resonance imaging (MRI) is the procedure which uses the resonant absorption and remission of radio waves by hydrogen nuclei to obtain images. MRI is noninvasive visualization of the velopharyngeal function and vocal tract without exposure to radiation or any known biohazards and provides better soft-tissue resolution. . .   However, only a few studies are available, still lack of outcome data and a high cost (around 6 times more expensive than videofluoroscopy).

[In sum] nasopharyngoscopy and videofluoroscopy are widely accepted as state-of-the art techniques for direct assessment of velopharyngeal movement [and insufficiency]. . . .”