Effect of Maxillary Osteotomy on Speech in Cleft Lip and Palate: Instrumental Outcomes of Velopharyngeal Function

Abstract

Objective:

To investigate the effect of maxillary osteotomy on velopharyngeal function in cleft lip and palate (CLP) using instrumental measures.

Design:

A prospective study.

Participants:

A consecutive series of 20 patients with CLP undergoing maxillary osteotomy by a single surgeon were seen at 0 to 3 months presurgery (T1), 3 months (T2), and 12 months (T3) post-surgery.

Interventions:

Nasalance was measured on the Nasometer II 6400. For videofluoroscopy and nasendoscopy data, visual perceptual ratings, for example, palatal lift angle (PLAn), and quantitative ratiometric measurements, for example, closure ratio (CRa), were made using a validated methodology and computer software. Reliability studies were undertaken for all instrumental measures.

Main Outcome Measures:

Repeated measures analysis of variance (with time at 3 levels) for nasalance and each velar parameter. Planned comparisons across pairs of time points (T1-T2, T1-T3, and T2-T3) including effect sizes.

Results:

A significant difference over time was found for nasalance (P = .001) and planned comparisons across pairs of time points were significant between T1 and T2 (P = .008), T1 and T3 (P = .002), but not between T2 and T3 (P = .459) providing evidence that maxillary osteotomy can impact on nasalance adversely and that the changes seen are permanent and stable. There were also significant differences over time for PLAn (P = .012) and CRa (P = −.059) and planned comparisons for both velar parameters reflected similar findings to those of nasalance.

Conclusions:

Maxillary osteotomy can adversely affect velopharyngeal function in patients with CLP. The study provides evidence for a much earlier post-surgery review even as early as 3 months after surgery.

Keywords

cleft palate velopharyngeal function orthognathic surgery speech

Get full access to this article

View all access options for this article.

References

Birch

Sommerlad

Bhatt

. Image analysis of lateral velopharyngeal closure in repaired cleft palates and normal palates. Br J Plast Surg. 1994;47(6):400–405.

Birch

Sommerlad

Fenn

Butterworth

. A study of the measurement errors associated with the analysis of velar movements assessed from lateral video fluoroscopic investigations. Cleft Palate Craniofac J. 1999;36(6):499–507.

Cheung

Chua

. A meta-analysis of cleft maxillary osteotomy and distraction osteogenesis. Int J Oral Maxillofac Surg. 2006;35(1):14–24.

Chua

Whitehill

Samman

Cheung

. Maxillary distraction versus orthognathic surgery in cleft lip and palate patients: effects on speech and velopharyngeal function. Int J Oral Maxillofac Surg. 2010;39(7):633–640.

Coe

. It’s the Effect Size, Stupid: What Effect Size is and Why it is Important; 2002. Accessed August 8, 2019. http://www.leeds.ac.uk/educol/documents/00002182.htm

Cohen

. A power primer. Psychol Bull. 1992;112(1):155–159.

Dalston

March

Vig

Witzel

Bumsted

. Minimal standards for reporting the results of surgery on patients with cleft lip, cleft palate, or both: a proposal. Cleft Palate J. 1988;25:3–7.

Egger

Smith

Phillips

. Meta-analysis: principles and procedures. BMJ. 1997;315(7121):1533–1537.

Faul

Erdfelder

Lang

A G

Buchner

. G*Power 3: a flexible statistical power analysis program for the social, behavioral, and biomedical sciences. Behav Res Methods. 2007;39(2):175–191.

10.

Gilleard

Sommerlad

Sell

Ghanem

Birch

. Nasendoscopic image analysis: an analysis of measurement uncertainties. In: Raposo do Amaral

Albino de Amaral

, eds. 11th International Congress on Cleft Lip and Palate and Related Craniofacial Anomalies International Proceedings. Medimond s.r.l. Monduzzi Editore, Bologna, Italy, 2009, pp. 179–184.

11.

Gilleard

. The Use of Nasendoscopy in Submucous Cleft Palate. University of London; 2008. Masters Dissertation.

12.

Glass

Peckham

Sanders

. Consequences of failure to meet assumptions underlying the fixed effects of analyses of variance and covariance. Rev Edu Res. 1972;42:237–288.

13.

Golding-Kushner

Argamaso

Cotton

Grames

Henningsson

Jones

Karnell

Klaiman

Lewin

Marsh

, et al. Standardization for the reporting of nasopharyngoscopy and multiview videofluoroscopy: a report from an international working group. Cleft Palate J. 1990;27(4):337–347.

14.

Good

Mulliken

Padwa

. Frequency of Le Fort I osteotomy after repaired cleft lip and palate or cleft palate. Cleft Palate-Craniofac J. 2007;44(4):396–401.

15.

Greenhalgh

. How to Read a Paper. 2nd ed. BMJ Books; 2001.

16.

Grunwell

Sell

. Speech and cleft palate/velopharyngeal anomalies. In: Watson

ACH

Sell

Grunwell

, eds. Management of Cleft Lip and Palate. Whurr Publishers; 2005, pp. 68–86.

17.

Harding

Grunwell

. Active versus passive cleft type speech characteristics. Int J Lang Commun Disord. 1988;33(3):329–352.

18.

Henningsson

Kuehn

Sell

Sweeney

Trost-Cardamone

Whitehill

. Universal parameters for reporting speech outcomes in individuals with cleft palate. Cleft Palate-Craniofac J. 2008;45(4):1–17.

19.

Impieri

Tonseth

Hide

Brinck

Hogevold

Filip

. Impact of orthognathic surgery on velopharyngeal function by evaluating speech and cephalometric radiographs. J Plast Reconstr Aesthet Surg. 2018;71(12):1786–1795.

20.

John

Sell

Sweeney

Harding-Bell

Williams

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

21.

John Wiley & Sons. (2020, Jan 14). Dummies: How to Interpret a Correlation Coefficient r. Accessed December 1, 2019. https://www.dummies.com/education/math/statistics/how-to-interpret-a-correlation-coefficient-r/

22.

Klassen

Riff

KWW

Longmire

Albert

Allen

Aydin

Baker

Cano

Chan

Courtemanche

, et al. Psychometric findings and normative values for the CLEFT-Q based on 2434 children and young adult patients with cleft lip and/or palate from 12 countries. CMAJ. 2018;190(15):E455–E462.

23.

Kuehn

Moller

. Speech and language issues in the cleft population: the state of the art. Cleft Palate-Craniofac J. 2000;37(4):1–35.

24.

Kummer

A W

. Cleft Palate and Craniofacial Anomalies. 2nd ed. Delmar Cengage Learning; 2008.

25.

Kummer

A W

. Current practice in assessing and reporting speech outcomes of Cleft Palate and velopharyngeal surgery: a survey of Cleft Palate/Craniofacial professionals. Cleft Palate-Craniofac. J. 2012;49(2):146–152.

26.

Lam

Starr

Perkins

Lewis

Eblen

Dunlap

Sie

KCY

. A comparison of nasendoscopy and Multiview videofluoroscopy in assessing velopharyngeal insufficiency. Otolaryngol Head Neck Surg. 2006:134:394–402.

27.

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.

28.

Lord

Corsello

. Diagnostic instruments in autistic spectrum disorders. In: Volkmar

Paul

Klin

Cohen

, eds. Handbook of Autism and Pervasive Developmental Disorders. Wiley; 2005, pp. 730–771.

29.

Mercer

NSG

Pigott

. Assessment and surgical management of velopharyngeal dysfunction. In: Watson

ACH

Sell

Grunwell

, eds. Management of Cleft Lip and Palate. Whurr Publishers; 2005, pp. 258–285.

30.

Orticochea

. Construction of a dynamic muscle sphincter in cleft palates. Plast Reconstr Surg. 1968;41(4):323–327.

31.

Pereira

Sell

Tuomainen

. The impact of maxillary osteotomy on speech outcomes in cleft lip and palate: an evidence-based approach to evaluating the literature. Cleft Palate Craniofac J. 2013;50(1):25–39.

32.

Pereira

. The Effect of Maxillary Advancement on Speech, Nasality and Velopharyngeal Function in Cleft lip and Palate. [PhD Thesis]. London; UCL Institute of Child Health; 2012.

33.

Pereira

Sell

Tuomainen

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

34.

Pruzansky

Mason

. The “stretch factor” in soft palate function. J Dent Res. 1969;48(5):972.

35.

Ross

. Treatment variables affecting facial growth in complete unilateral cleft lip and palate. Cleft Palate J. 1987;24(1):5–77.

36.

Schendel

Oeschlaeger

Wolford

Epker

. Velopharyngeal anatomy and maxillary advancement. J Maxillofac Surg. 1979;7(2):116–124.

37.

Sell

Harding

Grunwell

. A screening assessment of cleft palate speech (great ormond street speech assessment). Eur J of Dis of Commun. 1994;29(1):1–15.

38.

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.

39.

Sell

. Great Ormond Street Hospital Multiview Videofluoroscopic Assessment of Velopharyngeal Function Proforma. Unpublished Clinical Protocol, 1990.

40.

Sell

Pereira

. Instrumentation in the analysis of velopharyngeal mechanism. In: Howard

Lohmander

, eds. Cleft Palate Speech Assessment and Intervention. John Wile & Sons Ltd; 2011.

41.

Semb

. A study of facial growth in patients with unilateral cleft lip and palate treated by the Oslo CLP Team. Cleft Palate-Craniofac J. 1991;28(1):1–21.

42.

Shaw

Semb

Nelson

Brattstrom

Molsted

Prahl-Anderson

Gundlach

KKH

. The Eurocleft Project 1996-2000: overview. Journal of Cranio-Maxillofacial Surgery. 2001;29:131–140.

43.

Skolnick

Cohn

. Videofluoroscopic Studies of Speech in Patients With Cleft Palate. Springer-Verlag; 1989.

44.

Smedberg

Neovius

Lohmander

. Impact of maxillary advancement on speech and velopharyngeal function in patients with cleft lip and palate. Cleft Palate Craniofac J. 2014;51(3):334–343.

45.

Sommerlad

Mehendele

Birch

Sell

Hattee

Harland

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

46.

Sweeney

Sell

. Relationship between perceptual ratings of nasality and nasometry in children/adolescents with cleft palate and/or velopharyngeal dysfunction. Int J Lang Commun Disord. 2008;43(3):265–282.

47.

Sweeney

The Perceptual and Instrumental Assessment of Nasality and Nasal Airflow Errors Associated With Velopharyngeal Dysfunction. School of Clinical Speech and Language Studies, University of Dublin; 2000. Dissertation.

48.

Trindade

Yamashita

Suguimoto

Mazzottini

Trindade

Jr . Effects of orthognathic surgery on speech and breathing of subjects with cleft lip and palate: acoustic and aerodynamic assessment. Cleft Palate-Craniofac J. 2003;40(1):54–64.

49.

Trost

. Articulatory additions to the classical description of the speech of persons with cleft palate. Cleft Palate J. 1981;18(3):193–203.

50.

Watterson

Lewis

K E

. Test-retest nasalance score variability in hypernasal speakers. Cleft Palate-Craniofac J. 2006;43(4):415–419.

51.

Witzel

. Commentary. Cleft Palate J. 1989;26(3):199–200.

52.

Wong

Forrest

Goodacre

Klassen

. Measuring outcomes in craniofacial and pediatric plastic surgery. Clin Plast Surg. 2013;40(2):305–312.

53.

Zarcone

Rodgers

Iwata

Rourke

Dorsey

. Reliability analysis of the motivation assessment scale: a failure to replicate. Res Dev Disabil. 1991;12(4):349–360.