OBJECTIVES:The aim was to study the relationship between perceptual evaluation of speech variables related to velopharyngeal function and the pattern of nasal airflow during the velopharyngeal closing phase in speech in children with and without cleft palate.PARTICIPANTS:Fourteen children with cleft lip and palate or cleft palate only and 15 controls aged 7 and 10 years. All were native Swedish speakers.METHOD:Three experienced listeners performed a blinded perceptual speech evaluation. Nasal airflow was transduced with a pneumotachograph attached to a nasal mask. The duration from peak to 5% nasal airflow, maximum flow declination rate, and nasal airflow at selected points in time during the transition from nasal to stop consonants in bilabial and velar articulatory positions in sentences were estimated. The analysis was focused on the perceptual ratings of "velopharyngeal function" and "hypernasality."RESULTS:A strong association was found between ratings of "velopharyngeal function" and "hypernasality" and the pattern of nasal airflow during the bilabial nasal-to-stop combination /mp/. Both the sensitivity and specificity were 1.00 for the bilabial temporal airflow measure in relation to ratings of "velopharyngeal function." The nasal airflow rate during /p/ in /mp/ had a sensitivity of 1.00 and specificity of 0.92 to 0.96 in relation to ratings of "hypernasality."CONCLUSION:Assessment of the nasal airflow dynamics during the velopharyngeal closing phase in speech presents quantitative, objective data that appear to distinguish between perceptually normal and deviant velopharyngeal function with high sensitivity and specificity.

OBJECTIVE The purpose of the study was to study the speech outcome in a series of 5-year-old children born with an isolated cleft palate and compare the speech with that of noncleft children and to study the impact of cleft extent and additional malformation on the speech outcome. DESIGN A cross-sectional retrospective study. SETTING A university hospital serving a population of 1.5 million inhabitants. SUBJECTS Fifty-one patients with an isolated cleft palate; 22 of these had additional malformations. Thirteen noncleft children served as a reference group. INTERVENTIONS A primary soft palate repair at a mean of 8 months of age and a hard palate closure at a mean age of 4 years and 2 months if the cleft extended into the hard palate. MAIN OUTCOME MEASURES Perceptual judgment of seven speech variables assessed on a five-point scale by three experienced speech pathologists. RESULTS The cleft palate group had significantly higher frequency of speech symptoms related to velopharyngeal function than the reference group. There were, however, no significant differences in speech outcome between the subgroup with a nonsyndromic cleft and the reference group. Cleft extent had a significant impact on the variable retracted oral articulation while the presence of additional malformations had a significant impact on several variables related to velopharyngeal function and articulation errors. CONCLUSION Children with a cleft in the soft palate only, with no additional malformations, had satisfactory speech, while children with a cleft palate accompanied by additional malformations or as a part of a syndrome should be considered to be at risk for speech problems.

The regimen for treatment of children with cleft lip and palate in Göteborg, Sweden, until 1996 included early soft palate repair at 6-8 months of age and delayed closure of the hard palate at about 8 years of age to improve maxillary growth. The aims of this report were to describe the treatment concept and to present speech data of 59 children treated by this method. The speech of 38 children with unilateral and 21 with bilateral cleft lip and palate was evaluated perceptually from standardised tape recordings of repeated sentences and spontaneous speech at five ages from 3 to 16 years of age. All patients were not evaluated at each age level. The results showed a low prevalence of hypernasality after hard palate closure and pharyngeal flap surgery in only five children (8%), indicating a primary velopharyngeal insufficiency in less than 10% of the children. Only three children with bilateral clefts had glottal articulation when at pre-school age and no child with a unilateral cleft did. These results were interpreted as an indication of velopharyngeal competence (VPC) in most of the children. In addition, the speech problem found in these children consisted of retracted oral articulation of alveo-dental pressure plosives, which is almost always an indicator of VPC. However, we do consider that retracted oral articulation is a problem and to improve our results further we have decided to modify the technique for soft palate closure slightly and place the vomer flap further anteriorly to encourage narrowing of the cleft in the hard palate, and to close the hard palate at 3 years of age.

When cleft lip and palate treatment was introduced at Gothenburg in 1957, the procedure used was early bone grafting (EBG). By 1965, EBG had been omitted from the regimen, bone grafting being postponed until the appearance of mixed dentition. Analysis of the results of both techniques showed maxillary retrusion of different degrees. Accordingly, this routine was abandoned in 1975, being replaced by a procedure which is characterised by delayed closure of the hard palate (DCHP). Thus, the surgical procedure comprised the following steps: 1, lip closure at 1-2 months of age; 2, soft palate repair at 6-8 months; 3, final lip-nose surgery at 12 months; and 4, closure of the left in the hard palate, and bone grafting to the alveolar process during mixed dentition at about 8-10 years of age. Follow-up has shown the majority of patients to manifest acceptable speech development during childhood, though problems may occur in some cases. Maxillary growth has been found to be improved after DCHP, and at present the need of maxillary advancement surgery has been reduced to approximately 5% of cases, as compared with the former rates of 50% of cases among those treated with EBG, and of 25% among those treated with the vomer flap procedure.

The title of this paper highlights one of the major issues over many years in the treatment of the child born with a cleft lip and/or palate – the issue of when and how the cleft palate should be operated on, in order for the child to have the best possible opportunities for normal speech development. In spite of considerable research efforts in many centres over the world since the 1930s, we are still far from having the answers to these questions. Current research seems to indicate that a rephrasing will be necessary before we can answer the questions and further develop the habilitation of the cleft child (Harding & Grunwell, 1998).

The aim of this study was to describe the aerodynamics related to velopharyngeal function during speech in bilabial, dental, and velar articulatory positions in Swedish speakers. Repeated syllables including voiceless stop consonants and sentences including combinations of voiceless stops and nasal consonants were uttered by 11 normal adults. Oropharyngeal pressure was assessed with a miniature pressure transducer positioned transnasally, in combination with measurement of nasal pressure and nasal airflow. The corresponding velopharyngeal opening area was estimated. The results suggest that the velopharyngeal function during stop consonants is similar in different articulatory positions. Differences in oropharyngeal pressure and nasal airflow between bilabial versus dental and velar positions were found, presumably due to differences in volume and compliance of the vocal tract.

OBJECTIVE:This study was conducted to evaluate the relationship between size of residual clefts in the hard palate and speech.SUBJECTS:Fifteen 7-year-old children born with complete cleft lip and palate were investigated.METHODS:All of the children were treated according to a surgical regimen involving early soft palate repair and delayed hard palate closure. Measures were taken of the area, length, and maximal width of the residual cleft in the hard palate about a year before its closure and correlated with a perceptual judgment of several speech variables.RESULTS:Significant positive correlations were obtained between the size of the cleft and two variables: weak pressure consonants and hypernasality. Nasal escape was very common among the patients, and almost half the children had retracted palatal or velar articulation of dental stop consonants. Neither of these two variables correlated with the size of the residual cleft.CONCLUSION:Perceived oral pressure and, perhaps, resonance seem to be related to size of the opening of the residual cleft, whereas audible nasal escape and articulatory compensations are not, at least not the latter once established.

The speech of 20 children with cleft in the hard palate that had not yet been repaired was evaluated and analysed at 7 years of age. The cleft in the hard palate was open in 14 patients and functionally closed in six. All children were born with cleft lip and palate and treated surgically according to a routine that included delayed closure of the hard palate until age 8-10 years. The soft palate was repaired at approximately 6-8 months of age. Tape recordings were used for perceptual analysis of the speech. Maxillary casts were used to assess approximate age for functional closure of the residual cleft. Speech results showed only mild hypernasality for both groups of subjects which indicates acceptable velopharyngeal function in the whole group. Children with open residual clefts had significantly more nasal escape and a higher prevalence of compensatory retracted articulation than children with functionally closed clefts. The functional closure seems to have occurred at about the age of 18-36 months. Factors which appear to facilitate narrowing of the residual cleft include the original width of the cleft, the amount of tissue in the alveolar and palatal processes, and anterior placement of a vomer flap.

The influence of an open residual cleft in the hard palate on speech was studied in nine children with cleft lip and palate at about 7 years of age. The subjects were treated by early repair of the velum (before 12 months of age), whereas the repair of the cleft in the hard palate was postponed until about 8 years of age. Speech and velopharyngeal function were assessed systematically with the residual cleft open and temporarily covered with an oral bandage. Listeners' judgments, the Nasal Oral RAtio Meter (NORAM), videofluoroscopy, and cephalometrics were used for the analyses. Four patients were also examined with a pressure-flow technique. Nasality registered by NORAM, nasal escape, and weak pressure consonants judged by listeners were common but decreased appreciably when the residual cleft was covered. Retracted articulation was found in four patients (44%) and glottal compensations in one (11%), with no improvement after covering.

Pre-speech in 35 children with clefts of the lip and palate or palate only were analyzed for place and manner of articulation. Transcriptions were made from tape recorded babbling sequences. Two children without clefts were used as reference. All of the children with clefts were treated according to a regimen of early surgical repair of the velum cleft and delayed closure of the cleft in the hard palate. The frequency of selected phonetic features was calculated. Correlations between phonetic/perceptual and functional and morphological factors were tested. Supraglottal articulation dominated among all the children indicating a sufficient velopharyngeal mechanism. The results also showed correlations between cleft type and place of articulation. Anteriorly placed sounds (i.e., bilabial, dental, and alveolar sounds) occurred frequently among the children with cleft palate only and in the noncleft children. In children with cleft lip and palate, posteriorly placed articulations predominated. It was postulated that early intervention may have a positive effect on articulatory development.

Speech was analyzed about 1 year postoperatively in 30 patients with cleft lip and palate who were the first ones to undergo late closure of the hard palate in Gothenburg, Sweden. Fourteen had bilateral and 16 had unilateral clefts. Soft palate closure had been performed at the mean age of 8 months, and the hard palate was closed at the mean age of 8 years with a range of 7-11 years. Imitated and spontaneous speech was analyzed at an average of 15 months after palatal repair. Six percent had moderate to severe hypernasal speech and 23% had retraction of dental consonants. No glottal articulation was found. Hoarseness and deviant s articulation were frequent. For 6 of the patients the same speech analysis was also made 1-3 months postoperatively. At this time there was no change in the speech of these 6 children compared with preoperative speech. Thus, the closure of the palate did not improve the speech directly. The improvement of the speech seems to be a gradual process.

Maxillary morphology and dental occlusion were studied from infancy to age 10 years in 32 patients born with isolated cleft palate. Wardill-Kilner push back repair of the palate had been done at a mean age of 7.5 months. Measurements obtained from casts of the jaws showed that the average maxillary dimensions before as well as after operation were less than those reported for children without clefts. The mean reduction was similar whether the cleft reached into the hard palate or affected the soft palate only. Preoperative anterior maxillary arch width in particular, and also distance from scar line to selected teeth seemed to influence postoperative development of the maxillary dental arch in individual patients.

During the period 1958-1985, 230 patients with cleft palate were operated on in the Department of Plastic Surgery, University of Göteborg, Sweden. A modified push-back technique according to Wardill and Kilner was used. The children were operated on at a mean age of 13 months. They were divided into two groups, the first in which the cleft affected the velum only (n = 121) and the other in which it also affected the hard palate (n = 109). Postoperative dehiscences and fistulas occurred in 19 (8%) patients, of which 16 (15%) belonged to the group in which the cleft affected the hard palate. Only three (2%) of the 121 patients with a cleft in the soft palate only developed dehiscences. The total number of patients who had to be reoperated on because of dehiscences were 10 (4%) and palatopharyngeal flaps had to be performed in 25 patients (11%) because of speech problems.

The speech of 31 consecutive patients with isolated cleft palate was evaluated when they were between 10 and 14 years of age. All the children had Wardill-Kilner push-back repairs at a mean age of 7.9 months. Several speech variables were assessed by two trained listeners. In addition, an overall evaluation of the quality of the patients' speech was made by the listeners and by the patients themselves. The patients had some remaining speech problems, mainly hypernasality which was moderate or severe in 7 (23%). The prevalence of compensatory articulations was low. however (n = 4, 13%), and most patients thought that their own speech was normal or relatively normal.

This paper gives an overview of the research projects carried out in western Sweden with the aim of mapping the speech development of children with cleft lip and palate - all treated with late closure of the hard palate (8-10 yrs). Longitudinal study: The speech development of 15 children was analysed at the age of 4–6 years and again at age 7 years. Hypernasality had decreased but articulatory deviances were mainly unaffected at age 7. The study will continue after the closure of the residual cleft. Assessment of the speech of thirty children one year after closure of the hard palate showed fairly good speech except for deviant /s/-articulation and dysphonia. The analyses of articulation patterns in the babbling of children with clefts indicate that deviant articulatory patterns are established very early. Preliminary analyses of the speech of 5-year-old children, who have been treated with early stimulation of tongue tip and lip movements. indicate that articulatory deviances are less frequent in these children than in the children who were not given early stimulation. Intercenter study: The speech in 15 Swedish children was compared with the speech of 15 Danish children at age 10. The two Scandinavian centers differ in the timing of palatal surgery (Århus early and Göteborg delayed hard palate closure). The speech was found to be very similar in the two groups.Key Words: cleft palatespeech developmenthypernasalitydelayed palatal closure.

Since 1975, children with cleft lip and palate living in the western part of Sweden have been treated according to a regimen of early repair of the soft palate (at the age of 6-8 months) and late hard palate closure (at about 8-9 years of age). The present paper is a longitudinal study of 15 consecutive patients whose speech development was analysed at the mean ages (years:months) of 5:3, 7:0, 8:5, and 9:7 years. Hypernasality gradually decreased over the years whereas nasal escape almost completely ceased after closure of the residual cleft. There was no glottal articulation at any age. Despite the fact that retraction of apicodental consonants decreased in frequency with age and presumably with speech therapy, it was the main problem throughout the observation period. It was presumably caused by the residual cleft in the hard palate compensating for subnormal pressure in front of the opening to the nasal cavity.

Speech and maxillary development were analysed in two groups of patients with unilateral cleft lip and palate; both groups had early jaw orthopaedic treatment and a surgical regimen that included two-stage lip surgery (mean ages of 2 and 19 months) and soft palate repair (8 months). Closure of the hard palate was postponed until the children were 8 to 10 years of age. The first group comprised 10 consecutive patients who were analysed at 5 and 7 years of age, and the second group seven patients who were studied at the age of 5. Both groups were thus investigated before the repair of the cleft in the hard palate. In addition to surgical and jaw orthopaedic treatment, the second group of patients received early stimulation of lip and tongue tip movements. Our results indicated that hypernasality was less a problem than was retracted palatal or velar articulation of dental consonants. These deviations tended to be reduced, however, after early stimulation. There seemed to be no clear association between the size of the residual cleft in the hard palate and the extent of speech development. The average size of the residual cleft in our patients was comparatively small, and decreased further during follow up. We conclude that preschool children with unilateral cleft lip and palate may develop good speech, in spite of the residual cleft, if they use an intraoral plate and are given extra lip and tongue tip stimulation, together with early speech therapy if necessary.