Speech and velopharyngeal function in patients with hypernasality : an investigation utilizing listener judgments, instrumental analysis (NORAM), multiview videoradiography and nasopharyngoscopy

This investigation evaluated how velopharyngeal function and speech deficiencies related to velo pharyngeal insufficiency (VPI) were influenced by a) type of cleft, b) site and size of oronasal fistulas and c) pharyngeal flaps. In addition, the accelerometric device, NORAM was evaluated. NORAM, utilized for objectifying subjective listener judgments, was validated against listener judgments of hypernasality. A significant correlation was found between the NORAM values and the listener judgments. The speech of a consecutive series of 84 complete unilateral (UCLP) and 19 bilateral (BCLP) cleft lip and palate patients surgically treated with lip plasty simultaneously with early bone grafting and a V-Y retropositioning palatoplasty were compared to a control group of 40 non-cleft subjects and was found to differ significantly for all speech variables examined in spite of a considerable number of patients with speech therapy and pharyngeal flap surgery prior to the examination. Comparison of speech with respect to type of cleft revealed more deviant articulation in the BCLP group with more reduced intelligibility and a higher frequency of patients with speech therapy. Preoperative maxillary orthopedic treatment (T-traction) given to 45 of the UCLP patients did not improve speech outcome. Forty-three percent of the patients had oronasal fistulas preferably in the region of incisive fora men but only eighteen percent had fistulas affecting speech. The BCLP group had larger fistulas than the UCLP group and fistulas affecting speech were larger than fistulas not affecting speech. After temporarily covering fistulas that affected speech, listener judgments and NORAM-analysis confirmed that an oronasal fistula may influence velopharyngeal function negatively. This was also valid for very small fistulas. Videoradiography and nasopharyngoscopy failed to show the expected difference in width at rest between two types of pharyngeal flap used in a tailoring procedure for treatment of hypernasality. During speech, however, the flap used in patients with poor side wall activity demonstrated a bulge formation essential for eliminating VPI. Furthermore, a potential of adaptation of the pharyngeal wall adduction to different flap widths was found. Conclusion: The more severe malformations in BCLP patients led to more articulatory deficiencies with more reduced intelligibility than was found in the UCLP group. An explanation of the significant difference in speech between the CLP groups and non cleft subjects was the relative late timing of palatoplasty and late onset of speech therapy. A change in treatment plan was therefore introduced with earlier palatoplasty, tailor-made pharyngeal flaps and earlier involvement by the speech pathologist. NORAM was found to complement listener judgments in a variety of situations. Oronasal fistulas of even very small dimensions should be examined concerning influence on speech when planning pharyngeal flap surgery. The videoradiographic and nasopharyngoscopic methods of quantifying velopharyngeal function and configuration of pharyngeal flaps used in the investigation are highly recommended. The finding of a broadening of the flap base during speech and a functional plasticity of the bulge of the flaps transversely merged into the velum and the potential of adaptation of the pharyngeal wall adduction have motivated us to continue with the tailoring procedure