Benchmarking Speech,Velopharyngeal Function Outcomes and Surgical Characteristics Following the Sommerlad Protocol and Palate Repair Technique

Abstract

Objective:

To report speech and velopharyngeal function (VPF) outcomes, and surgical characteristics, at age 5 following early complete palate closure using the Sommerlad protocol.

Design:

A retrospective, descriptive, cross-sectional consecutive series.

Setting:

A regional twin site center; a district general hospital and tertiary children’s hospital.

Participants:

Between 1993 and 2006, 877 participants underwent surgery; 712 (81%) were eligible for inclusion; 391 (55%) were included, 321 (45%) excluded. Thirteen percent had bilateral cleft lip and palate (CLP), 40% unilateral CLP, and 47% isolated cleft palate.

Intervention:

Lip and vomerine flap repair at 3 months of age (BCLP, UCLP) with soft palate closure using radical muscle dissection and retropositioning at a mean age of 6.6 months, range 4 to 23 months, as described and undertaken by Sommerlad.

Outcome Measures:

Velopharyngeal Composite (VPC) CAPS-A and articulation summary scores derived from analysis using the Cleft Audit Protocol for Speech-Augmented.

Results:

A VPC-SUM CAPS-A score of “0” was found in 97% reflecting adequate VPF; 73% had no cleft articulation difficulties. The BCLP group had the poorest articulation. Secondary speech surgery rate was 2.6% and 10.7% had fistula repair. Levator muscle quality and degree of retropositioning was associated with speech outcomes related to VPF. 2.6% had current features of VPI.

Conclusions:

Complete palate closure by around 6 months of age by the surgeon who described the technique led to excellent perceived VPF and very good speech outcomes at age 5, with less speech therapy and secondary speech surgery than commonly reported. These findings serve as a benchmark for the Sommerlad protocol and technique.

Keywords

articulation nasality palatoplasty resonance speech disorders surgical technique velopharyngeal function

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References

Ahl

Harding-Bell

. Comparing methodologies in a series of speech outcome studies. Cleft Palate-Craniofac J. 2017;55(1):35–44.

Altman

. Practical Statistics for Medical Research. CRC Press; 1990.

Andrades

Espinosa-los-Monteros

Shell

IV DH

Todd

Jessica

Sudeep

Peter

John

III . The importance of radical intravelar veloplasty during two-flap palatoplasty. Plastic Reconst Surg. 2008;122(4):1121–1130.

Barron

. Failed appointments. Who misses them, why they are missed, and what can be done. Primary Care. 1980;7(4):563–574.

Bearn

Mildinhall

Murphy

Murray

Sell

Shaw

Williams

Sandy

. Cleft lip and palate care in the United Kingdom—the clinical standards advisory group (CSAG) study. Part 4: outcome comparisons, training, and conclusions. Cleft Palate-Craniofac J. 2001;38(1):38–43.

Becker

Hansson

. Low rate of fistula formation after Sommerlad palatoplasty with or without lateral incisions: an analysis of risk factors for formation of fistulas after palatoplasty. J Plast Reconstr Aesthet Surg. 2013;66(5):697–703.

Bowen

. Lisping—When /s/ and /z/ are Hard to Say; 2011. Accessed March 5, 2019. https://www.speech-language-therapy.com/index.php?option=com_content&view=article&id=86: lisp

Britton

Albery

Bowden

Harding-Bell

Phippen

Sell

. A cross-sectional cohort study of speech in five-year-olds with cleft palate +/- lip to support development of national audit standards: benchmarking speech standards in the United Kingdom. Cleft Palate-Craniofac J. 2014;51(4):431–451.

Brothers

Dalston

Peterson

Lawrence

. Comparison of the Furlow double-opposing Z-palatoplasty with the Wardill-Kilner procedure for isolated clefts of the soft palate. Plastic Reconst Surg. 1995;95(6):969–977.

10.

Bruneel

Bettens

De Bodt

Roche

Bonte

Van Lierde

. Speech outcomes following Sommerlad primary palatoplasty: results of the Ghent University Hospital. J Commu Disord. 2018;72(1):111–121.

11.

Brunnegard

Lohmander

. A cross-sectional study of speech in 10-year-old children with cleft palate: results and issues of rater reliability. Cleft Palate-Craniofac J. 2007;44(1):33–44.

12.

Cairns

Wilson

de Lange

Mehendale

. Sommerlad palate repair—burden of care and predictive factors for speech outcomes at age 5 years—a study of the first consecutive cases of a single surgeon. Paper presented at ESPRAS Congress; Edinburgh, United Kingdom: 2014.

13.

Chapman

Baylis

Trost-Cardamone

Kelly Nett

Angela

Cindy

Anna

Kristina

Anne Harding

Triona

, et al. The Americleft Speech Project: a training and reliability study. Cleft Palate-Craniofac J. 2016;53(1):93–108.

14.

Chapman

Hardin-Jones

Goldstein

Halter

Havlik

Schulte

. Timing of palatal surgery and speech outcome. Cleft Palate-Craniofac J. 2008;45(3):297–308.

15.

Chapman

Hardin-Jones

Halter

. Vocal development of 9 month old babies with cleft palate. J Speech Lang Hear Res. 2001;44(6):1268–1284.

16.

Chapman

Willadsen

. The development of speech in children with cleft palate. In: Howard

Lohmander

, eds. Cleft Palate Speech: Assessment and Intervention. Wiley-Blackwell; 2011:55–85.

17.

Choa

Slator

Jeremy

Robinson

Franklin

Roberts

Winter

Extence

Collard

Clark

. Identifying the effect of cleft type, deprivation and ethnicity on speech and dental outcomes in UK cleft patients: a multi-centred study. J Plastic, Reconst Aesthetic Surg. 2014;67(12):1637–1643.

18.

Cleft Registry and Audit Network (CRANE). Publications. Accessed October 28, 2019. www.crane-database.org.uk

19.

Clinical Standards Advisory Group Cleft Lip and/or Palate. HMSO, ISBN 0-11-322103-7. London; 1998.

20.

D’Andréa

Maschi

Savoldelli

Caci

Bailleux

. Otologic outcomes with two different surgical protocols in patients with a cleft palate: a retrospective study. Cleft Palate-Craniofac J. 2018;55(9):1289–1295.

21.

Davari

Zahedi

Derakhshandeh

. The prevalence of hypernasality after primary cleft palate surgery in children. J Isfahan Med School. 2012;30(175):(page numbers in Arabic).

22.

Derakhshandeh

Poorjavad

. The study of speech disorders and middle ear diseases following primary palatoplasty in children with cleft palate. J Isfahan Med School. 2011;29:222–229.

23.

Dissaux

Grollemund

Bodin

, et al. Evaluation of 5-year-old children with complete cleft lip and palate: multicenter study. Part 2: functional results. J Craniomaxillofac Surg. 2016;44(2):94–103.

24.

Dorf

Curtin

. Early cleft palate repair and speech outcome. Plast Reconstr Surg. 1982;70(1):74–81.

25.

Doucet

Herlin

Captier

Baylon

Verdeil

Bigorre

. Speech outcomes of early palatal repair with or without intravelar veloplasty in children with complete unilateral cleft lip and palate. British J Oral Maxillofac Surg. 2013;51(8):845–850.

26.

Evans

Renfrew

. The timing of primary cleft palate repair. Scand J Plast Reconstr Surg. 1974;8(1-2):153–155.

27.

Feragen

Stock

. When there is more than a cleft: psychological adjustment when a cleft is associated with an additional condition. Cleft Palate-Craniofac J. 2014;51(1):5–14.

28.

Fisher

Sommerlad

. Cleft lip, cleft palate, and velopharyngeal insufficiency. Plast Reconstr Surg. 2011;128(4):342e–360e.

29.

Fitzsimons

Copley

Van Der Meulen

Panagamuwa

Deacon

. Grommet surgery in children with orofacial clefts in England. Cleft Palate-Craniofac J. 2017;54(1):80–89.

30.

Furlow

. Cleft palate repair by double opposing z-plasty. Plast Reconstr Surg. 1986;78:724–735.

31.

Gani

Kinshuck

Sharma

. A review of hearing loss in cleft palate patients. Int J Otolaryngol. 2012;2012:6. Article ID 548698.

32.

Goh

Tang

Hashim

Annamalay

Abd Rahman

. Hearing status and behavioural patterns among school aged children with cleft lip and/or palate. Int J Pediatr Otorhinol. 2019;118(2):1–5.

33.

Goldenberg

. Stickler syndrome. 2015; Accessed November 11, 2018. https://rarediseases.org/rare-diseases/stickler-syndrome/

34.

Grobbelaar

Hudson

Fernandes

Lentin

. Speech results after repair of the cleft soft palate. Plast Reconstr Surg. 1995;95(7):1150–1154.

35.

Gustafsson

Heliovaara

Leikola

Rautio

. Incidence of speech-correcting surgery in children with isolated cleft palate. Cleft Palate-Craniofac J. 2018;55(8):1115–1121.

36.

Hardin-Jones

Jones

. Speech production of preschoolers with cleft palate. Cleft Palate-Craniofac J. 2005;42(1):7–13.

37.

Hardwicke

Richards

Cafferky

Underwood

Ter Horst

Slator

. Outcomes of cleft palate repair in patients with Pierre Robin sequence: a matched case-control study. Plast Reconstr Surg. 2016;137(3):927–935.

38.

Hassan

Askar

. Does palatal muscle reconstruction affect the functional outcome of cleft palate surgery? Plast Reconstr Surg. 2007;119(6):1859–1865.

39.

Hay

Patel

Haria

Sommerlad

Maxillary growth in cleft lip and palate patients, with and without vomerine flap closure of the hard palate at the time of lip repair: a retrospective analysis of prospectively collected nonrandomized data, with 10-year cephalometric outcomes. Cleft Palate-Craniofac J. 2018;55(9):1205–1210.

40.

Hens

Sell

Pinkstone

Birch

Hay

Sommerlad

Kangesu

. Palate lengthening by buccinator myomucosal flaps for velopharyngeal insufficiency. Cleft Palate-Craniofac J. 2013;50(5):84–91.

41.

Henningson

Willadsen

. Cross linguistic perspectives on speech assessment in cleft palate. In: Howard

Lohmander

, eds. Cleft Palate Speech: Assessment and Intervention. Wiley-Blackwell; 2011:167–179.

42.

Hosseinabad

Derakhshandeh

Mostaajeran

Abdali

Davari

Hassanzadeh

Kummer

. Incidence of velopharyngeal insufficiency and oronasal fistulae after cleft palate repair: a retrospective study of children referred to Isfahan Cleft Care Team between 2005 and 2009. Int J Pediat Otorhinol. 2015;79:1722–1726.

43.

Hutters

Henningsson

. Speech outcome following treatment in cross-linguistic cleft palate studies: methodological implications. Cleft Palate-Craniofac J. 2004;41(5):544–549.

44.

Hynes

. Pharyngoplasty by muscle transplantation. British J Plast Surg. 1950:128–135.

45.

Hynes

. The results of pharyngoplasty by muscle transplantation in “failed cleft palate” cases, with special reference to the influence of the pharynx on voice production. British J Plast Surg. 1993;46(5):430–439.

46.

Jerger

. Clinical experience with impedance audiometry. Arch Otolaryngol. 1970;92(4):311–324.

47.

John

Sell

Sweeney

Harding-Bell

Williams

The cleft audit protocol for speech—augmented: a validated and reliable measure for auditing cleft speech. Cleft Palate-Craniofacial J. 2006;43(3):272–288.

48.

Jolleys

. A review of the results of operations on cleft palates with reference to maxillary growth and speech function. British J Plast Surg. 1954;7(3):229–241.

49.

Kaplan

. Cleft palate repair at three months? Ann Plastic Surg. 1981;7(10):179–190.

50.

Kirschner

Wang

Jawad

Duran

Cohen

Solot

Randall

LaRossa

. Cleft-palate repair by modified Furlow double-opposing Z-plasty: the children’s hospital of Philadelphia experience. Plast Reconstr Surg. 1999;104(7):1998–2010; discussion 2011-1994.

51.

Kitchin

Grames

Naidoo

Skolnick

Schoenborn

Snyder-Warwick

Patel

. Surgical, speech, and audiologic outcomes in patients with orofacial cleft and Van der Woude syndrome. J Craniofac Surg. 2019;30(5):1484–1487.

52.

Klintö

Falk

Wilhelmsson

Schönmeyr

Becker

. Speech in 5-year-olds with cleft palate with or without cleft lip treated with primary palatal surgery with muscle reconstruction according to Sommerlad. Cleft Palate-Craniofacial J. 2018;55(10):1399–1408.

53.

Kuehn

Ettema

Goldwasser

Barkmeier

. Magnetic resonance imaging of the levator veli palatini muscle before and after primary palatoplasty. Cleft Palate-Craniofacial J. 2004;41(6):584–592.

54.

Lewin

Heller

Kojak

. Speech results after Millard island flap repair in cleft palate and other velopharyngeal insufficiencies. Cleft Palate J. 1975;12(3):263–269.

55.

Lidén

. The scope and application of current audiometric tests. J Laryngol Otol. 1969;83(6):507–520.

56.

Lindsay

Witzel

Cleft palate repair: Von Langenbeck technique. In: Bardach

Morris

, eds. Multidisciplinary Management of Cleft Lip and Palate. WB Saunders Company; 1990:303.

57.

Lohmander-Agerskov

Doteval

Lith

Soderpalm

. Speech and velopharyngeal function in children with an open residual cleft in the hard palate, and the influence of temporary covering. Cleft Palate-Craniofac J. 1996;33:324–332.

58.

Lohmander

Persson

. A longitudinal study of speech production in Swedish children with unilateral cleft lip and palate and two-stage palatal repair. Cleft Palate-Craniofac J. 2008; 45(1): 32–41.

59.

Lohmander

Willadsen

Persson

Henningsson

Bowden

Hutters

. Methodology for speech assessment in the Scandcleft project—an international randomized clinical trial on palatal surgery: experiences from a pilot study. Cleft Palate-Craniofac J. 2009;46(4):347–362.

60.

Lohmander

. Surgical intervention and speech outcomes in cleft lip and palate. In: Howard

Lohmander

, eds. Cleft Palate Speech: Assessment and Intervention. Wiley-Blackwell; 2011:55–85.

61.

Lohmander

Olsson

Flynn

. Early consonant production in Swedish infants with and without unilateral cleft lip and palate and two-stage palatal repair. Cleft Palate-Craniofac J. 2011;48(3):271–285.

62.

Lohmander

Hagberg

Persson

Willadsen

Lundeborg

Davies

Havstam

Boers

Kisling-Moller

Alaluusua

, et al. Validity of auditory perceptual assessment of velopharyngeal function and dysfunction—the VPC-sum and the VPC-rate. Clin Linguist Phonet. 2017;31(7-9):589–597.

63.

Lohmander

Persson

Willadsen

Lundeborg

Alaluusua

Aukner

Bau

Boers

Bowden

Davies

, et al. Scandcleft randomised trials of primary surgery for unilateral cleft lip and palate: 4. Speech outcomes in 5-year-olds-velopharyngeal competency and hypernasality. J Plastic Surg Hand Surg. 2017;51(1):27–37.

64.

Shi

Zheng

Wang

. Incidence of palatal fistula after palatoplasty with levator veli palatini retropositioning according to Sommerlad. British J Oral Maxillofac Surg. 2010;48(8):637–640.

65.

Luyten

Bettens

D’Haeseleer

De Ley

Hodges

Galiwango

Bonte

Vermeersch

Van Lierde

. Impact of early synchronous lip and palatal repair on speech. Folia Phoniatrica et Logopaedica. 2013;65(6):303–311.

66.

Luyten

Bettens

D’Haeseleer

De Ley

Hodges

Galiwango

Bonte

Vermeersch

Van Lierde

. The impact of palatal repair before and after 6 months of age on speech characteristics. Int J Pediat Otorhinol. 2014;78(5):787–798.

67.

Maggiulli

Hay

Mars

Worrell

Green

Sommerlad

. Early effect of vomerine flap closure of the hard palate at the time of lip repair on the alveolar gap and other maxillary dimensions. Cleft Palate-Craniofac J. 2014;51(1):43–48.

68.

Mahoney

M-H

Swan

Fisher

. Prospective analysis of presurgical risk factors for outcomes in primary palatoplasty. Plastic Reconstr Surg. 2013;132(1):165–171.

69.

Mapar

Khanlar

Sadeghi

Hossein

Mehrdad

Heydar Ali

Fatemeh

. The incidence of velopharyngeal insufficiency and oronasal fistula after primary palatal surgery with Sommerlad intravelar veloplasty: a retrospective study in Isfahan Cleft Care Team. Int J Pediat Otorhinol. 2019;120:6–10.

70.

Marrinan

LaBrie

Mulliken

. Velopharyngeal function in nonsyndromic cleft palate: relevance of surgical technique, age at repair, and cleft type. Cleft Palate-Craniofac J. 1998; 35(2):95–100.

71.

Mirotznik

Ginzler

Zagon

Baptiste

. Using the health belief model to explain clinic appointment-keeping for the management of a chronic disease condition. J Comm Health. 1998;23(3):195–210.

72.

Moar

Sweet

Beale

. Fistula rate after primary palatal repair with intravelarveloplasty: a retrospective three-year audit of six units (NorCleft) in the UK. British J Oral Maxillofac Surg. 2016;54(6):634–637.

73.

Morice

Renault

Soure

Chapuis

Trichet Zbide

Kadlub

Giudice

Vazquez

Picard

. Predictors of speech outcomes in children with Pierre Robin sequence. J Craniomaxillofac Surg. 2018;46(3):479–484.

74.

Mungall

. Trend towards centralisation of hospital services, and its effect on access to care for rural and remote communities in the UK. Rural Remote Health. 2005;5(2):390.

75.

Ness

Wills

Waylen

Al Ghatam

Jones

TEM

Preston

Ireland

Persson

Smallridge

Hall

, et al. Centralization of cleft care in the UK. Part 6: a tale of two studies. Orthodont Craniofac Res. 2015;18(4):56–62.

76.

Nopoulos

Richman

Andreasen

Murray

Schutte

. Cognitive dysfunction in adults with Van der Woude syndrome. Gene Med. 2007;9(4):213.

77.

Nyberg

Neovius

Lohmander

. Speech outcomes at 5 and 10 years of age after one-stage palatal repair with muscle reconstruction in children born with isolated cleft palate. J Plast Surg Hand Surg. 2018;52(1):20–29.

78.

Nyberg

Peterson

Lohmander

. Speech outcomes at age 5 and 10 years in unilateral cleft lip and palate after one-stage palatal repair with minimal incision technique—a longitudinal perspective. Int J Paediat Otorhino. 2014;78(1):1662–1670.

79.

Nyberg

Westberg

Neovius

Larson

Henningsson

. Speech results after one-stage palatoplasty with or without muscle reconstruction for isolated cleft palate. Cleft Palate-Craniofac J. 2010;47(1):92–103.

80.

O’Gara

Logemann

. Phonetic analyses of the speech development of babies with cleft palate. Cleft Palate J. 1988;25(2):122–134.

81.

O’Gara

Logemann

Rademaker

. Phonetic features by babies with unilateral cleft lip and palate. Cleft Palate-Craniofac J. 1994;31(6):446–451.

82.

Oller

. The Emergence of the Speech Capacity. Lawrence Erlbaum Associates; 2000.

83.

Patel

Sullivan

Murthy

Marrinan

Mulliken

. Speech outcome after palatal repair in nonsyndromic versus syndromic Robin sequence. Plast Reconstr Surg. 2012:577–584.

84.

Peet

. The oxford technique of cleft palate repair. Plastic Recons Surg Trans Bull. 1961;28(1):282–294.

85.

Pereira

Sell

Tuomainen

. Effect of maxillary osteotomy on speech in cleft lip and palate: perceptual outcomes of velopharyngeal function. Int J Lang Comm Disord. 2013;48(6):640–650.

86.

Pereira

. The VPC-SUM CAPS-A: notes from an osteotomy study. Invited Presentation at The Cleft Lip and Palate Speech and Language Therapy Clinical Excellence Network Meeting; 2019; London, United Kingdom.

87.

Persson

Elander

Lohmander-Agerskov

Söderpalm

. Speech outcomes in isolated cleft palate: impact of cleft extent and additional malformations. Cleft Palate-Craniofacial J. 2002;39(4):397–408.

88.

Persson

Lohmander

Elander

. Speech in children with an isolated cleft palate: a longitudinal perspective. Cleft Palate-Craniofacial J. 2006;43(3):295–309.

89.

Persson

Pedersen

Hayden

Bowden

Aukner

Vindenes

Abyholm

Withby

Willadsen

Lohmander

. Scand Cleft Project Trial 3: comparison of speech outcomes in relation to sequence in 2-stage palatal repair procedures in 5-year-olds with unilateral cleft lip and palate. Cleft Palate-Craniofacial J. 2020;57(3):352–363.

90.

Peterson-Falzone

SJ.

Optimal age for palatoplasty to facilitate normal speech development: what is the evidence? In: Berkowitz

, ed. Cleft Lip and Palate. Springer; 2006:691–703.

91.

Posnett

. Is bigger better? Concentration in the provision of secondary care. British Med J. 1999;319(7216):1063–1065.

92.

Purdie

Jae-Hyun

Harding-Bell

. Hearing loss and the impact on speech in children with cleft palate. In: Harding-Bell

, ed. Case Studies in Cleft Palate Speech Data Analysis and Principled Intervention. J&R Press; 2019:225–272.

93.

Randall

LaRossa

Fakhraee

Cohen

. Cleft palate closure at 3-7 months of age: a preliminary report. Plastic Recons Surg. 1983;71(3):624–628.

94.

Rautio

Andersen

Bolund

Hukki

Vindenes

Davenport

Arctander

Larson

Berggren

Abyholm

, et al. Scand cleft randomised trials of primary surgery for unilateral cleft lip and palate: 2. Surgical results. J Plastic Surg Hand Surg. 2017;51(1):14–20.

95.

Reardon

Brustowicz

Marrinan

Mulliken

Padwa

. Anatomic severity, midfacial growth, and speech outcomes in Van der Woude/popliteal pterygium syndromes compared to nonsyndromic cleft lip/palate. Cleft Palate-Craniofac J. 2015;52(6):676–681.

96.

Reddy

Vaidhyanathan

Bergé

Kuijpers-Jagtman

. Maxillofacial growth and speech outcome after one-stage or two-stage palatoplasty in unilateral cleft lip and palate. A systematic review. J Cranio-Maxillofac Surg. 2017;45(6):995–1003.

97.

Rintala

Haapanen

. The correlation between training and skill of the surgeon and reoperation rate for persistent cleft palate speech. British J Oral Maxillofac Surg. 1995;33(5):295–298.

98.

Robertson

McKeown

Bello-Rojas

Yeon-Jeen

Amy

Barbara

Mark

Ian

. Use of buccal myomucosal flap in secondary cleft palate repair. Plastic Reconst Surg. 2008;122(3):910–917.

99.

Rohrich

Rowsell

Johns

Drury

Grieg

Watson

Godfrey

Poole

. Timing of hard palatal closure: a critical long-term analysis. Plastic Reconst Surg. 1996;98(2):236–246.

100.

Rohrich

Love

Byrd

Johns

. Optimal timing of cleft palate closure. Plastic Reconst Surg. 2000;106(2):413–421.

101.

Rossell-Perry

Cotrinal-Rabanal

Caceres-Nano

. One-flap palatoplasty: a cohort study to evaluate a technique for unilateral cleft palate repair. Plastic Reconst Surg Global Open. 2015;3(4):e373.

102.

Scherer

D’Antonio

McGahey

. Early intervention for speech impairment in children with cleft palate. Cleft Palate-Craniofacial J. 2008;45(1):18–31.

103.

Sell

. Issues in perceptual speech analysis in cleft palate and related disorders: a review. Int J Lang Commun Disord. 2005;40(2):103–121.

104.

Sell

Grunwell

Mildinhall

Murphy

Cornish

Bearn

Shaw

Murray

Williams

Sandy

. Cleft lip and palate care in the United Kingdom—the clinical standards advisory group (CSAG) study. Part 3: speech outcomes. Cleft Palate-Craniofac J. 2001;38(1):30–37.

105.

Sell

Harding

Grunwell

. GOS. SP. ASS.’98: an assessment for speech disorders associated with cleft palate and/or velopharyngeal dysfunction (revised). Int J Lang Commun Disord. 1999;34(1):17–33.

106.

Sell

John

Harding Bell

Sweeney

Hegarty

Freeman

. Cleft Audit Protocol for Speech (CAPS-A): a comprehensive training package for speech analysis. Int J Lang Commun Disord. 2009;44(4):529–548.

107.

Sell

Mildinhall

Albery

Wills

Sandy

Ness

. The cleft care UK study. Part 4: perceptual speech outcomes. Orthodon Craniofac Res. 2015;18(suppl 2):36–46.

108.

Sell

Southby

Wren

Wills

Hall

Mahmoud

Waylen

Sandy

Ness

. Centre-level variation in speech outcome and interventions, and factors associated with poor speech outcomes in 5-year-old children with non-syndromic unilateral cleft lip and palate: the Cleft Care UK study. Part 4. Orthodon Craniofac Res. 2017;20(6):27–39.

109.

Semb

Enemark

Friede

Paulin

Lilja

Rautio

Andersen

Abyholm

Lohmander

Shaw

, et al. Scandcleft randomised trials of primary surgery for unilateral cleft lip and palate: 1. Planning and management. J Plastic Surg Hand Surg. 2017;51(1):2–13.

110.

Shaw

Semb

. The Scandcleft randomised trials of primary surgery for unilateral cleft lip and palate: 11. What next? J Plastic Surg Hand Surg. 2017;51(1):88–93.

111.

Shaw

Semb

Lohmander

Persson

Willadsen

Clayton-Smith

Trindade

Munro

Gamble

Harman

, et al. Timing of primary surgery for cleft palate (TOPS): protocol for a randomised trial of palate surgery at 6 months versus 12 months of age. British Med J Open. 2019;9:e029780.

112.

Sheahan

Blayney

. Cleft palate and otitis media with effusion: a review. Revue de Laryngologie Otologie Rhinologie. 2003;124(3):171–177.

113.

Shriberg

McSweeny

Anderson

Thomas

Michael

Jordan

Katherina

Christopher

Heather

David

. Transitioning from analog to digital audio recording in childhood speech sound disorders. Clin Lingui Phone. 2005;19(4):335–359.

114.

Sim

Wright

. The kappa statistic in reliability studies: use, interpretation, and sample size requirements. Phys Therap. 2005;85(3):257–268.

115.

Slator

Perisanidou

Waylen

Sandy

Ness

Wills

. Range and timing of surgery, and surgical sequences used, in primary repair of complete unilateral cleft lip and palate: the Cleft Care UK study. Orthod Craniofac Res. 2020;23(2):166–173. doi:10.1111/ocr.12355.

116.

Smillie

Robertson

Yule

Wynne

Russell

CJH

. Complications of ventilation tube insertion in children with and without cleft palate. A nested case-control comparison. Otolaryngol Head Neck Surg. 2014;140(10):940–943.

117.

Smyth

. Cleft palate outcomes and prognostic impact of palatal fistula on subsequent velopharyngeal function—a retrospective cohort study. Cleft Palate-Craniofac J. 2019;56(8):1008–1012.

118.

Sommerlad

. A technique for cleft palate repair. Plast Reconstr Surg. 2003;112(6):1542–1548.

119.

Sommerlad

. The use of the operating microscope for cleft palate repair and pharyngoplasty. Plast Reconstr Surg. 2003;112(6):1540–1541.

120.

Sommerlad

. Surgery of the cleft palate: repair using the operating microscope with radical muscle retropositioning: the GosstA approach. B-ENT. 2006;2(suppl 4):32–34.

121.

Sommerlad

. Challenges for cleft care in the developing and the developed world. In: Mars

Sell

Habel

, eds. Management of Cleft Lip and Palate in the Developing World. John Wiley & Sons Ltd; 2008:31–36.

122.

Sommerlad

. Cleft palate repair with minimal hard palate dissection and radical muscle reconstruction. In: Comprehensive Cleft Care. 2nd ed. CRC Press; 2016;2:962–975.

123.

Sommerlad

Boorman

. Muscle reconstruction in cleft and submucous cleft palates. British J Plastic Surg. 1989;42(3):360.

124.

Sommerlad

Henley

Birch

Harland

Moiemen

Boorman

. Cleft palate re-repair—a clinical and radiographic study of 32 consecutive cases. British J Plastic Surg. 1994;47(6):406–410.

125.

Sommerlad

Mehendale

Birch

Sell

Hattee

Harland

. Palate re-repair revisited. Cleft Palate Craniofac J. 2002;39(3):295–307.

126.

Stoel-Gammon

. Prelinguistic vocal development: measurement and predictions. In: Ferguson

Menn

Stoel-Gammon

, eds. Phonological Development: Models, Research, Implications. York Press; 1992:439–456.

127.

Stransky

Basta

Solot

Cohen

Low

Larossa

Jackson

. Do patients with Pierre Robin sequence have worse outcomes after cleft palate surgery? Ann Plastic Surg. 2013;71(2):292–296.

128.

Sullivan

Marrinan

La Brie

Rogers

Mulliken

. Palatoplasty outcomes in nonsyndromic patients with cleft palate: a 29-year assessment of one surgeon’s experience. J Craniofac Surg. 2009;20(3):612–616.

129.

Szczepura

. Access to health care for ethnic minority populations. Postgrad Med J. 2005;81(1):141–147.

130.

Viera

Garrett

. Understanding interobserver agreement: the kappa statistic. Family Med. 2005;37(5):360–363.

131.

Vihman

. Early syllables and the construction of phonology. In: Ferguson

Menn

Stoel-Gammon

, eds. Phonological Development: Models, research, Implications. York Press; 1992:393–422.

132.

Wallace

. A history of the repair of cleft lip and palate in Britain before World War II. Ann Plastic Surg. 1987;19(3):266–275.

133.

World Health Organisation. Grades of hearing impairment. 2019; Accessed October 25, 2018. https://www.who.int/pbd/deafness/hearing_impairment_grades/en/

134.

Willadsen

Albrechtsen

. Phonetic description of babbling in Danish toddlers born with and without unilateral cleft lip and palate. Cleft Palate Craniofac J. 2006;43(2):189–200.

135.

Willadsen

Lohmander

Persson

Lundberg

Alaluusua

Aukner

Bau

Boers

Bowden

Davies

, et al. Scandcleft randomised trials of primary surgery for unilateral cleft lip and palate: 5. Speech outcomes in 5-year-olds-consonant proficiency and errors. J Plast Surg Hand Surg. 2017;51(1):38–51.

136.

Williams

Sandy

Thomas

Sell

Sterne

. Influence of surgeon’s experience on speech outcome in cleft lip and palate. Lancet. 1999;354(9191):1697–1698.

137.

Williams

Seagle

Pegoraro-Krook

Souza

Garla

Silva

Machado Neto

Dutka

JCR

Nackashi

Boggs

, et al. Prospective clinical trial comparing outcome measures between Furlow and von Langenbeck palatoplasties for UCLP. Ann Plastic Surg. 2011;66(2):154–163.

138.

Yang

Yifei

Heng

Bing

Qian

. Velopharyngeal function of patients with cleft palate after primary palatoplasty: relevance of sex, age, and cleft type. J Craniofac Surg. 2013;24(3):923–928.

139.

Ysunza

Pamplona

Mendoza

García-Velasco

Aguilar

Guerrero

. Speech outcome and maxillary growth in patients with unilateral complete cleft lip/palate operated on at 6 versus 12 months of age. Plastic Reconst Surg. 1998;102(3):675–679.