Short term speech outcomes in late palate repair

M. Cleves, A. Lizarraga, L. Bermudez C. Arboleda, B. Dueñas, M. Tavera, M. Echeverry, M. Montero, E. Villagra, M. Hanayama.

Operation Smile, Inc. Fundación Operación Sonrisa Colombia. Fisulab.  Operación Sonrisa Paraguay. Operación Sonrisa Venezuela. Operação Sorriso do Brasil.

Current data indicates that the extended delay in palatal closure increases the likelihood of persistent velopharyngeal insufficiency (VPI) and abnormal articulation patterns. In this study, the recording of speech samples of 13 patients from three South American countries, were rated by six speech pathologists using the ‘universal parameters’ criteria described by the Speech Parameters Group (Henningsson et al., 2008). Understandability was evaluated also by a group of three laypersons. The results support the notion that delayed surgery without speech therapy does not provide significant improvement of consonant production errors. Interestingly, various degrees of improvement in understandability were found after cleft palate repair, along with small improvements in hypernasality, nasal emission and speech intelligibility.

INTRODUCTION

Several factors influence the success of palate repair, including primary surgical technique, cleft type and severity, and age at primary palatoplasty. Residual speech characteristics of patients with repaired cleft palate may include persistent VPI and abnormal articulation patterns. Current discussions on the relationship between these factors, speech therapy and cleft palate repair have been focused on the ideal age for the corrective surgical procedure (Drury, 1996). The majority of studies undertaken since the 1950s have included children of two years and above (Jones et al., 2003). The last 30 years have seen a surge in proponents of cleft palate surgery completion anywhere from one day to two years of age (Chapman et al, 2008; Denk and Magee, 1996), with some emphasizing the need for the interventions to be performed before canonical babbling is initiated (Jones et al., 2003). 

While the debate over the earliest appropriate time to perform surgery continues, few studies in the last couple of decades have investigated the results of late palate. Generally, studies of late palatal surgery in the developing world have also failed to provide comprehensive information about the effects of palate surgery on speech (Sell & Grunwell, 1990). Consequently, the content of Ortiz-Monasterio’s earlier publications of the 1960s and 1970s remain widely accepted on the theme. From these, it is understood that patients from 6-12 years receive some benefit from surgery if combined with phonetic training, but there is little effect in teenagers and none in adults with well established speech patterns. Still, some authors believe that surgery, even if performed late, will improve hypernasality and speech intelligibility (Sell & Grunwell, 1990).

Since the main goal of primary palatoplasty is to provide a functional mechanism for velopharyngeal closure, the best way to assess the success of the procedure should be the perceptual evaluation of the speech outcomes. This study examined the speech skills of patients seven years and older prior to primary palate surgery and 8-12 months post surgery. The patients did not receive speech therapy due to their lack of access to multidisciplinary treatment centers.

METHODS

Thirteen children who received late primary palate surgery in Paraguay, Venezuela and Colombia during Operation Smile’s 25th Anniversary missions in November 2007 participated in the study. All patients were seven years of age or older at the time of their first evaluation. The patient sample included seven females and six males, with an age range of 7-30 years (median=10 years). Of the group, seven patients had unilateral cleft lip and palate (UCLP); five had bilateral cleft lip and palate (BCLP) and one had an isolated cleft palate. These patients did not return to the initial follow up sessions offered to them by Operation Smile and consequently did not undergo any speech therapy. All the patients in the study and the speech pathology evaluators spoke Spanish. There were no patients with additional congenital anomalies or developmental delays. 

Clinical data was collected through regular medical records. Speech samples with the five sentences designed for Operation Smile’s postoperative program and one minute conversational samples, were recorded digitally with a Sony Pro Hi-MD MZ-M200 recorder and its accessory microphone, Sony ECM-DS70P, before surgery and 8-12 months after. The speech sample included four sentences containing oral consonants and one sentence with nasal consonants. Without knowing whether the recordings were taken before or after palate surgery, six speech pathologists evaluated the samples using the universal parameter guidelines described by Henningsoon and colleagues (2008). Three laypersons evaluated blindly the understandability of the samples. A sample T-test was performed for every dependent variable, followed by a non-parametric Wilcoxon test if significance was observed.

RESULTS

Hypernasality: statistical analysis performed on the outcomes of speech evaluation of these patients before and after surgery shows a small but, significant improvement in Hypernasality (P < 0.05). Eight of the 13 patients showed progress. Of these, six went from severe to moderate rating of hypernasality and two also improved from severe to mild.

Audible Nasal Air Emission and/or Nasal Turbulence: analysis demonstrated significant changes from the baseline before surgery (P< 0.05), with eight of 13 patients showing improvement. Of these, two went from having intermittent nasal emissions to results within the normal limits; four improved from frequent to intermittent nasal emissions and two others went from frequent emissions to within the normal limits. 

Speech Understandability: significant progress was observed by the speech therapists from baseline before surgery (P< 0.05).

Speech Acceptability: the evaluation of speech was perceived to have minimal but significant changes in five patients. Of these, one went from severe to normal, two from severe to mild, and two from severe to moderate, respectively (P<0.05).

Consonant Production Errors: abnormal backing of oral target to post-uvular place, abnormal backing remaining in oral place, nasal fricative and substitution of nasal consonant for oral pressure consonant remained unchanged after surgery. 

Overall Postoperative Speech: no patterns related to type of cleft, age or sex at the time of surgery, were observed. Minimal but significant changes were found in more than 60 percent of the patients in hypernasality, nasal emission and speech understandability (P<0.05). In speech acceptability, while only a small percentage of patients (40%) received better evaluations, their improvement was more advanced. There were no changes in consonant production errors. Non-speech therapist evaluators denoted improvement in 10 patients respectively.

DISCUSSION

Results of our study support the notion that when patients are operated at a later stage and do not receive speech therapy, there is no significant improvement in consonant production errors. However, there was a small but statistically significant improvement in hypernasality, nasal emission, and speech intelligibility. These findings are consistent with those reported by Dorf and Curtin (1982), stating that unlike misarticulation of consonants, surgical repairs can correct excessive nasal air escape. 

Disadvantages of this study include a small patient sample and non-standardized variables such as surgical technique, or surgeons’ experience.

An interesting preliminary observation of the study is the improvement observed in most patients as rated by non-speech pathologists. Although non-technical, these results may warrant further studies as one of the biggest challenges faced by patients with cleft palate is their ability to be understood by their peers not by the specialist. Based in the data presented here, it is still worth repairing the cleft palate late in life when patient has not had the opportunity to get have access to early palatoplasty.

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