International Journal of Pediatric Otorhinolaryngology
Hearing and speech assessment of cleft palate patients after palatal closure: Long-term results
Introduction
It is self evident that a physical defect that affects the structures of the mouth and face has the potential to influence articulatory development. Cleft palate has therefore traditionally been primarily considered as disorders of the vocal tract. The existence of this craniofacial deformity may give rise tohearing and psychosocial problems, in addition, to the more obvious difficulties such as feeding and speech disorders. With regard to clinical management, it is important to take a holistic approach to the assessesment and treatment of children with cleft palate. They require therefore a comprehensive screening of hearing, speech and language development, which must be evaluated pre- and post-surgically according to any physical, psychosocial and linguistic factors associated with the structural abnormality. There is general agreement that the language skills of cleft palate children tend to be delayed, particularly in the development of expressive language [1], [2]. Cleft palate has the potential to influence articulatory development. This may effect the infant's phonetic output even during the pre-speech stage of development and prior to palate repair. Poorer articulation procifiency might be expected after primary palatoplasty ut it might also be expected of those patients who receive primary surgical repair of the palate following onset of phonological development.
It appears that atypical patterns of articulation may develop as the child attempts to mask and compensate for the perceptual consequences of an incompetent mechanism prior to palatoplasty [3].
The effect of the operation itself on the child's vocalizations needs to be considered.
The causes of the delay may be more closely related to associated hearing loss psychosocial factors than the direct effects of the physical defects and the surgical management itself.
In our study we tried to approach the influence of post-surgical hearing output and type of cleft on speech proficiency of our patients according to their age.
No one in child health and development is immune to the controversy surrounding otitis media. Some maintain that repeated episodes of otitis media with effusion early in life and the accompanying reduction in hearing sensitivity compromise cognitive and language development [4]. Others hold that the minimal reduction in either the quantity or quality of auditory stimulation need not interrupt the acquisition of language, because the infant can actively search out alternative sources of information [5].
We concur with the hypothesis of Roland et al. [6] that the relationship between OME and language is mediated by hearing. That is, there is a direct causal connection between hearing and language and an indirect causal connection between OME and language based on the relationship between OME and hearing. In the above study a significant relationship between the middle ear status and hearing was confirmed.
A relationship between mild fluctuating hearing levels from OME and language performance was observed in a prospective, longitudinal investigation of high-risk infants [7] the results of which showed that by 2 years both expressive and receptive language performance is higher for children with better hearing between 6 and 18 months.
On the other hand, there is a direct connection between language and velopharyngeal valving. Warren et al. [8] studied timing characteristics associated with velopharyngeal closure in eleven subjects who had no more than a 25 db conductive hearing loss in the better ear; the subjects were hypernasal but had adequate closure on pressure flow testing. The results showed several unique timing features, including a delay of about 59 ms in achieval closure, a longer interval of nasal emission and a shorter duration of actual velopharyngeal closure. According the same study, some speakers with hearing loss do not use velopharyngeal closure for sounds requiring closure but may achieve closure on sounds not requiring it.
The purpose of the present investigation was to develop a clinical methodology to assess speech and hearing impairment after surgical repair of the cleft and to determine the relative importance and the long-term consequences of each cleft type and age to the velopharyngeal and eustachian tube function.
Section snippets
Patients
Between 1983–1992 42 patients (25 boys and 17 girls) of different cleft types were treated with primary surgical repair (1-stage palatoplasty) at the Pediatric Surgical Department. The initial subject pool of this study included these 42 patients with cleft lip and palate who participated in the research project of a newly formed CLP team which consists of Pediatric surgeons, otorhinolaryngologists, speech–language pathologists, orthodontists. The study took place at the Thessaloniki Medical
Audiometric evaluation
According to the audiometric evaluation the young patients were classified into three groups. Group I included 13 patients (31%) with normal hearing, group IIa included 26 patients (62%) with mild conductive hearing loss and group IIb 3 patients (1%) with moderate conductive hearing loss.
Otomicroscopy revealed
Serous otitis media in 21 patients (50%) at their first visit; 10 out of them (42%) were treated with bilateral ventilation tube insertion and the rest received conservative treatment with antibiotics,
Discussion
Mild and moderate conductive fluctuating hearing loss is well described to be one of the major problems in cleft palate population [14], [15]. It has been suggested that because our cleft palate patients after 1-stage palatoplasty suffered, at a great percentage (69%), from mild to moderate hearing loss, their early persistent seromucous otitis may be responsible not only for the later otologic abnormalities and hearing impairment but also for their reportedly prevalent impairment at speech and
Conclusions
In our study, where we had the opportunity to study the relations between post-surgical hearing and speech impairment of patients with clefts our findings support the hypothesis that serous otitis persistent post-surgically may be responsible not only for the otologic abnormalities but also for the reportedly prevalent impairments of speech and language.
Our study, also, examined the expected from other studies-sequence that risk of persistent velopharyngeal insufficiency and post-surgical
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Cited by (42)
The effect of soft palate reconstruction with the da Vinci robot on middle ear function in children: an observational study
2023, International Journal of Oral and Maxillofacial SurgeryFunctional cleft palate surgery
2023, Journal of Oral Biology and Craniofacial ResearchSpeech outcomes after palatal closure in 3–7-year-old children
2022, Brazilian Journal of OtorhinolaryngologyCitation Excerpt :In contrast, this finding is in line with those of Derakhshandeh and Poorjavad,9 Rezaei et al.,10 the earlier studies that reported the prevalence of moderate-severe hypernasality among preschool cleft palate children visited in ICCT respectively during 2005–2007, and 2006–2009. Our findings also showed a higher rate of compensatory misarticulation (71.1%) compared with other studies (about 25%).5–7 These observations are again in line with the previous studies performed in ICCT.9,10
The impact of hearing loss on speech outcomes in 5-year-old children with cleft palate ± lip: A longitudinal cohort study
2021, International Journal of Pediatric OtorhinolaryngologyCitation Excerpt :Whilst hypernasality is a feature in the speech of profoundly deaf individuals [31,32] only mild and moderate hearing loss was seen in this study. It is challenging to fully account for the findings of other studies reporting a link between hypernasality and hearing [10,11]. The CAPS-A does not, however, provide a consonant inventory and future research could consider if specific sounds are particularly vulnerable to hearing loss in the CP ± L population.
Effect of Cleft Palate Closure Technique on Speech and Middle Ear Outcome: A Systematic Review
2019, Journal of Oral and Maxillofacial SurgeryDelayed primary palatal closure in resource-poor countries: Speech results in Ugandan older children and young adults with cleft (lip and) palate
2017, Journal of Communication DisordersCitation Excerpt :However, results of a retrospective analysis using Spearman’s rank order correlation coefficient, showed no significant correlations (p > 0.05) between the age at the time of palatal closure and speech results (perceptual evaluation of airflow deviation errors, nasometry and phonetic and phonological analysis), nor between the age at the time of the speech assessment and speech results. Also, information regarding dental status, more specifically dental occlusion (Farronato, Giannini, Riva, Galbiati, & Maspero, 2012; Mølsted, Brattström, Prahl-Andersen, Shaw, & Semb, 2005; Van Lierde et al., 2015), hearing status, more specifically middle ear status (Paliobei, Psifidis, & Anagnostopoulos, 2005; Schönweiler et al., 1999; Sheahan, Miller, Sheahan, Earley, & Blayney, 2003), cognition, self-efficacy beliefs and socio-economic factors, was not taken into account, although these variables might also have influenced the patients’ speech outcome. Over the past decades, several authors have emphasized the need for a standardized approach in reporting speech outcomes of cleft palate patients in order to facilitate comparisons.