Keywords
cleft lip with or without cleft palate - cleft palate - speech - hard palate closure
- alveolar bone grafting
Introduction
Depending on the phenotype and extent of oral cleft, patients may suffer from functional
and aesthetic impairments such as transient delay in development of speech and disorders
in articulation and resonance as well as maxillary hypoplasia.[1]
[2]
Speech of patients affected with cleft palate is often characterized by resonance
and articulation errors. Resonance characteristics are hypernasality (air flow into
nasal cavity) and nasal emission (nasal air release). It is affected by a combination
of structures of the nasal, pharyngeal, and oral cavities and the balance of sound
energy in those cavities.[3] Articulation errors occur because of changed articulation placement due to anatomical
anomalies. Consequently, children may develop new motor speech patterns such as compensatory
articulation patterns to compensate for these speech disorders and facial grimacing,
as an attempt to inhibit nasal air leak by constriction of the nasal/facial musculature.[2]
[4] A general hypothesis is that in case of prolonged persistence of an anterior palatal
defect, these compensatory mechanisms are hard to eliminate at older age.[2]
[5]
[6]
[7]
[8]
The ultimate objective of cleft care is finding a balance between the best intelligible
speech and reaching the optimal midfacial growth at skeletal maturity and, at the
same time, reducing the burden of care for patients with cleft. Although current literature
is still not conclusive on the exact impact of the timing of palatal repair on midfacial
growth, the focus of the treatment is increasingly shifted on the enhancement of speech
at an earliest age as possible. This is based on the objective that quality of speech
may substantially influence a person's psychosocial health and social acceptance and
integration in society even at a young age.[9]
Although there is a general consensus on the timing of lip- and soft palate closure
and alveolar bone grafting (ABG), the timing of hard palate closure (HPC) has been
debated for decades and varies worldwide between 6 months and 13 years of age.[10]
[11]
[12]
[13] Some studies advocate that by earlier closure of the hard palate, incorporation
of articulatory errors would be prevented resulting in a better speech outcome.[5]
[8]
[14]
Reports on synchronous delayed hard palate closure (DHPC) and secondary ABG and its
influence on resonance and articulation are sparse. This study aims to evaluate the
documented changes in resonance and articulatory patterns in individuals with an isolated
cleft lip, alveolus, and palate (CLAP) who underwent a two-stage palatal closure with
simultaneous closure of the hard palate and secondary ABG.
Methods
This retrospective cohort study includes all children diagnosed with a nonsyndromic
CLAP who underwent a synchronous DHPC and ABG between 9 and 12 years of age from January
2013 to June 2018 at authors' institution. Patients were excluded in case of presence
of other congenital deformities or patients with an incomplete documentation of speech
assessments.
Local Cleft Treatment Protocol during Study Period
All patients included in this study were treated according to the local treatment
protocol for unilateral CLAP as shown in [Table 1]. Soft palate closure was conducted using the Widmaier–Perko technique. Within the
first 2 years of life, only observation of spoken language and speech was conducted
during multidisciplinary outpatient visits. The first assessment of speech and language
development took place at 2 years of age. All speech samples were collected in standardized
manner with regard to the setting and recording, according to Sell.[15] Speech assessments were conducted by one speech-language pathologist experienced
in cleft care. When the development of speech and language skills was not at an appropriate
level or when early speech production was inadequate, speech therapy was recommended.
Speech therapy would be performed by speech-language pathologists outside of the hospital
with varying experience in the treatment of cleft patients. In case of insufficient
progression after speech therapy or when velopharyngeal dysfunction was suspected
during perceptual speech assessments, nasoendoscopy was conducted at the age of 4
or when the patient would be cooperative enough. If velopharyngeal insufficiency (VPI)
was observed, velopharyngeal repair was recommended at an earlier age. Prosthetic
speech appliances were not used in our institutions in this cohort.
Table 1
Local treatment protocol during the study period
|
Timing
|
Performed procedure
|
|
3–5 months
|
Lip repair (according to the Millard technique), with/without primary correction of
the nasal ala and/or placement of grommets when indicated
|
|
9–11 months
|
Soft palate closure (according to the Perko technique)
|
|
9–12 years[a]
|
Simultaneous hard palate closure (according to von Langenbeck) and alveolar bone grafting
|
|
18+ years
|
If indicated, orthognathic surgery after completion of facial skeletal growth and
secondary nose and/or lip corrections
|
a Timing of alveolar bone grafting was determined by the extent of the maturity of
the canine roots (two-thirds) or the degree of eruption of the lateral incisors.
Standardized speech assessments were conducted before and after HPC and alveolar repair.
These were performed using the speech assessment protocol developed by Meijer in collaboration
with the Dutch Association for Cleft and Craniofacial Anomalies based on the framework
that was devised for the Eurocleft Speech Project[16] (Shaw, 2001[33]).
The timing of HPC was commonly determined by the eruption state of the canine. If
earlier alveolar bone repair would enhance the eruption of the lateral incisor, ABG
would be planned based on the development of the lateral incisor and thus would be
performed at an earlier stage.
Data Collection
Data were extracted from electronic patient files. Data included demographic patient
characteristics, cleft lateralization and extent, comorbidities, psychosocial diagnoses,
the need for special education in the past or at present time, surgical procedures,
postoperative complications, pre- and postsurgical detailed speech assessments, and
information on the presence of hearing impairment in the past or at the present time.
The retrieved speech assessments were reviewed by the speech pathologist who had performed
the speech assessments. Presence of hearing impairment or hearing loss was determined
by an otolaryngologist. If it was expected that the degree of hearing impairment could
influence speech development and articulation, the patient was excluded from participation
in the study.
Data collection and protection took place according to the privacy regulations of
the tertiary care center. Since subjects are not being subjected to any handling,
nor are there rules of human behavior being imposed, Institutional Review Board Approval
was waived by the ethical committee of the hospital (MEC-2017-400).
Speech Assessments
Speech was assessed at approximately 4 weeks before and 15 weeks after surgery. Speech
evaluations were standardized and proceeded as follows by a single qualified speech-language
pathologist who is closely involved in the cleft patients' care. All children had
the same language background (Dutch) as the speech pathologist. Video recordings were
collected using the same equipment and technique, with the examiner and camera in
opposite direction of the individual.
The perceptual speech analysis was conducted before and after surgery according to
the speech assessment protocol developed by Meijer and was based on reading standardized
sentences and words.[16] These speech sounds were scored in several categories such as cleft-related articulation
disorders, phonetic disorders (errors in positioning the tip of the tongue during
production of alveolar fricatives), and phonological disorders not related to the
cleft (the latter was not analyzed in this study). Only the cleft-related articulation
disorder was further analyzed in this study and was scored as present or absent based
on a general impression of the articulation ([Table 2]).
Table 2
Speech assessment protocol used during the study period
|
Articulation disorders
|
Nasality
|
Hypernasality degree
|
Facial grimacing
|
Speech intelligibility
|
|
1: Present
2: Absent
|
0: Normal
1: Hypernasal
2: Hyponasal
3: Mixed-type
|
1: Mild
2: Moderate
3: Severe
|
0: No grimacing
1: Nasal grimace
2: Nasal and midfacial grimace
3: Nasal, midfacial, and frontal grimacing
|
1: Intelligible speech
2: Speech differs, without commenting of others
3: Speech differs, with commenting of others
4: Hardly intelligible speech
5: No intelligible speech
|
To assess resonance (hypernasal, hyponasal, mixed-type), a subjective evaluation based
on standardized words, vowels, sentences, and spontaneous speech was performed. For
an objective assessment of nasal emission, the mirror test and nasometry (Nasometer
II Model 6450 KayPENTAX) were used. In case of contradicting findings, the subjective
nasality measurements would be conclusive since it is expected that this would also
be the perception of the listener during everyday life. The resonance was scored based
on the severity scale shown in [Table 2].
Speech intelligibility was rated using a five-point scale ranging from normal/intelligible
speech to completely unintelligible speech ([Table 2]). The score was based on spontaneous connected speech, lasting 2 to 5 minutes.
Statistical Analysis
Statistical analyses are performed using the IBM Statistical Package for the Social
Sciences (Version 21.0, SPSS Inc, Chicago, IL). For intergroup assessments over time
(pre- and postoperative), Wilcoxon signed-rank test for ordinal variables and McNemar
test for binary variables were used. To determine if variable outcomes were dependent
on the cleft type (unilateral or bilateral), chi-square and Fisher's exact tests were
used. A Spearman's test was used to determine correlations. Probabilities less than
0.05 were accepted as significant.
Results
Participants
Initially, a total of 51 patients with CLAP were eligible for this study, 3 patients
were excluded due to lack of complete data. Eventually 48 patients, 33 with unilateral
CLAP and 15 with bilateral CLAP, were included.
Of the 15 bilateral cases, 10 were bilaterally complete clefts, 3 were unilaterally
complete, 1 was bilaterally incomplete, and in 1 patient the extent of cleft was unknown.
The mean follow-up time was 10.1 (range 7–13) weeks, representing the time between
the pre- and postoperative speech assessment.
Patient Characteristics
Most patients were male and had a complete cleft ([Table 3]). The cleft was determined as complete when it was anteriorly extended into the
nasal floor. Nine patients (27%) were adopted and eight of these patients underwent
primary closure of the lip and correction of the nose in the country of adoption.
Five patients (10%) suffered from bilateral hearing loss in the past or at present
time. These cases were reevaluated by an ENT specialist who concluded that speech
disorders in these children were all associated with the cleft and were not related
to their hearing impairment.
Table 3
Patient characteristics
|
Variables
|
CLAP patients (n = 48)
N (%)
|
|
Cleft side
|
|
Unilateral
|
33
|
|
Left
|
21 (64)
|
|
Right
|
12 (36)
|
|
Bilateral
|
15
|
|
Sex
|
|
Male
|
28 (58)
|
|
Female
|
20 (42)
|
|
Cleft extent
|
|
Complete
|
36 (75)
|
|
Incomplete
|
8 (17)
|
|
Right C, left IC
|
2 (4)
|
|
Left C, right IC
|
1 (2)
|
|
Unknown[a]
|
1 (2)
|
|
Adopted
|
|
China
|
7 (15)
|
|
Philippines
|
1 (2)
|
|
Brazil
|
1 (2)
|
Abbreviations: C, complete; CLAP, cleft lip, alveolus, and palate; IC, incomplete.
Values are presented as number (%).
a Primary surgery in a different country with no documentation on the cleft extent.
Surgical Treatment
DHPC and ABG were performed by two qualified oral and maxillofacial surgeons with
extensive experience in cleft surgery. During the study period, the von Langenbeck
palatoplasty was the preferred technique for closing the hard palate. This was also
the case in bilateral cases. In all patients, autologous bone from iliac crest was
harvested for alveolar repair.
The procedure was performed at the mean age of 10.5 (range 7–13) years. Two patients
with unilateral CLAP suffered from postoperative complications in the alveolar area
(fistula, bone sequestration) which needed surgical revision. One patient with bilateral
CLAP developed a fistula in the anterior palate following synchronous closure. The
palatal defect was closed 3 years later performing another von Langenbeck procedure.
Velopharyngoplasty was performed in 15 patients before simultaneous DHPC and ABG at
a mean age of 6.1 (range 2–9) years. This procedure was performed by plastic surgeons
specialized in cleft surgery, according to the Orticochea technique (4 patients) or
by using a cranial-based pharyngeal flap (11 patients). Two patients suffered from
minor complications (small fistula, mucosal dehiscence) without a need for revision
surgery, one had undergone velopharyngoplasty according to Orticochea technique, and
another one had received a cranial-based pharyngeal flap. Two other patients were
reoperated due to persistent VPI (one during and one after simultaneous DHPC and ABG).
Velopharyngoplasty (intravelar veloplasty) was performed in three patients after DHPC
and ABG. Two of these patients were scored as severely hypernasal and one as moderately
hypernasal both before and after DHPC and ABG. After conducting nasoendoscopy, VPI
was found to be the cause of (severe) hypernasality which persisted after intravelar
veloplasty in two of these patients. One patient underwent additional surgery for
correction of VPI using cranial-based pharyngeal flap.
Speech Outcomes
Resonance
Abnormal resonance (hypernasal, hyponasal, or a mixed-type) was observed in 45 of
48 patients (94%) preoperatively. An improvement was seen in a total of 19 patients
(42%; p < 0.001) after surgery ([Table 4]). Resonance was considered improved when preoperative hypernasal speech changed
to normal, hyponasal, or mixed-type. This was due to the fact that speech is perceived
as more intelligible when a hyponasal or mixed resonance is present compared with
a hypernasal speech.
Table 4
Presence of articulation disorders and hypernasal speech preoperative versus postoperative
|
Variable
|
Present preoperative
|
Present postoperative
|
Improvement
|
p-Value[a]
|
|
Cleft-related articulation disorder
|
45 (94)
|
41 (85)
|
4 (8)
|
0.375
|
|
Hypernasal speech
|
43 (90)
|
26 (54)
|
19 (40)[b]
|
<0.001
|
Values are presented as number (%).
a McNemar test.
b Resonance was considered improved when hypernasal speech changed to hyponasal, mixed-type,
or normal.
Hypernasal speech was found in 43 patients (90%) before and in 26 patients (54%) after
surgical repair of the hard palate and alveolus ([Table 4]). In 15 (58%) of these patients, hypernasal speech was scored as mild. Normal resonance
was observed in 17 (35%) patients during postoperative evaluation, two of them presented
with normal resonance also prior to surgery ([Table 5]). The improvement in overall resonance did not differ between patients with unilateral
and bilateral CLAP (p = 0.171; [Table 6]).
Table 5
Postoperative changes in resonance in all 48 cleft lip, alveolus, and palate patients
|
Change in resonance
|
Number of patients
|
|
Hypernasal to normal
|
15
|
|
Remained hypernasal
|
25
|
|
Hypernasal to hyponasal
|
3
|
|
Hypernasal to mixed-type
|
1
|
|
Mixed-type to hypernasal
|
1
|
|
Remained normal
|
2
|
Table 6
Differences in improvement of speech disorders between unilateral and bilateral cleft
lip, alveolus, and palate patients
|
Variable
|
Unilateral CLAP (n = 33)
|
Bilateral CLAP (n = 15)
|
p-Value[a]
|
|
Articulation disorders
|
1 (3)
|
3 (20)
|
0.227
|
|
Hypernasality
|
14 (42)
|
5 (33)
|
0.328
|
|
Hypernasality degree
|
21 (64)
|
8 (53)
|
0.499
|
|
Facial grimacing
|
8 (24)
|
5 (33)
|
0.509
|
|
Speech intelligibility
|
20 (61)
|
12 (80)
|
0.186
|
Abbreviation: CLAP, cleft lip, alveolus, and palate.
Values are presented as number (%).
a Chi-square test or Fisher's exact test.
The severity of hypernasal speech decreased in 29 patients (67%) at postoperative
evaluation (p < 0.001), remained unaffected in 16 patients (37%), and increased in 3 patients (7%).
There was no difference in outcome regarding hypernasal speech or the severity grade
between patients with unilateral and bilateral CLAP (p = 0.498 and p = 0.499; [Table 6]).
Cleft-related Articulation Disorders
Cleft-related articulation disorders were present in 45 patients (94%). In four of
these patients, articulation was restored during the follow-up period (p = 0.375; [Table 4]). There was no difference in improvement of articulatory errors between patients
with unilateral or bilateral CLAP (p = 0.227; [Table 6]).
Facial Grimacing
The severity of facial grimacing decreased in 13 patients (27%) during the postoperative
follow-up (p = 0.015). In 33 patients (69%) no change was observed, in 2 patients (6%) the grimacing
seemed to have increased from score 1 to 2. One of them had persistent hypernasality
due to VPI and one developed mild hypernasal speech postoperatively. No difference
was noted between patients with unilateral and bilateral CLAP (p = 0.509; [Table 6]).
Speech Intelligibility
Intelligibility of speech improved in 32 patients (67%; p < 0.001). Intelligibility remained unchanged in 11 patients (23%) and speech was
assessed as less intelligible in 4 patients (8%). There was no difference in the improvement
of speech intelligibility between patients with unilateral and bilateral CLAP (p = 0.186; [Table 6]). A positive correlation between the hypernasality degree and the intelligibility
score was observed both pre- and postoperative (ρ = 0.419, p = 0.003 and ρ = 0.559, p < 0.001).
Discussion
In this study, we aimed to determine the changes in resonance, articulatory patterns,
and speech intelligibility in individuals with an isolated CLAP following a DHPC combined
with secondary ABG between 9 and 12 years of age. Therefore, we evaluated 48 patients
with unilateral and bilateral CLAP. We found a significant reduction in the number
of patients with hypernasal speech following surgery. Additionally, in patients who
had remaining hypernasal speech postoperatively, a significant decrease in severity
of hypernasality was seen, which was mild in the majority of cases. No significant
reduction in articulatory errors and grimacing (compensatory mechanisms) was seen.
The speech intelligibility however was significantly improved during postoperative
follow-up. No difference was found between the unilateral and bilateral group. Since
the size of the bilateral group is relatively small, this group was not separately
analyzed.
Within the past surgical cleft treatment protocol in our institution, according to
which the studied cohort was treated, the focus of the treatment was minimizing the
need for orthognatic surgery during adolescence by limiting the detrimental effects
of early surgical procedures on the midfacial growth, while providing multidisciplinary
care to achieve the best possible speech development. The philosophy on DHPC was based
on earlier literature revealing that the most midfacial growth takes place before
the age of 5 years and that irreversible injury after early surgery of the palate
results in reduction of midfacial growth capacity.[17]
[18]
[19] A study of 251 patients who were subjected to the delayed two-stage palatoplasty
in our institution reports a frequency of 11.2% of Le Fort I osteotomies which is
relatively low compared with a frequency up to 70% reported by previous studies.[20]
[21]
[22]
[23]
[24] In the latter study, a higher number of previous surgical interventions was found
in patients with an indication for orthognathic surgery compared with those without.[20]
Hypernasality
Hypernasality decreased from 90 to 54% after HPC and alveolar repair. The severity
of hypernasal speech was reduced in 67% of patients so that in 31% of all patients
only mild hypernasality was seen after surgery. Three patients were diagnosed with
VPI prior to the surgery and were diagnosed with severe and moderate hypernasal speech
which persisted postoperatively. All three of them were surgically treated for VPI
multiple times after DHPC and ABG. Here, VPI was the main cause of hypernasality which
decreased to mild and moderate scores following speech-enhancing procedures.
In 65% of patients postoperative compensatory facial grimacing persisted as mild,
presenting as nasal valve flaring or contraction of the nasal bridge. Two patients
presented with a higher score of facial grimace. In one of them, this could be explained
by the severe VPI for which he was surgically treated multiple times after the delayed
closure of the hard palate. One patient who did not present with preoperative grimace
developed mild nasal contractions. The severity of hypernasal speech also increased
which could be the reason for the occurrence of mild grimace.
In the study of Lohmander et al, speech outcomes of 55 Swedish patients treated according
to a two-stage palatal closure with DHPC at a mean age of 8 years were evaluated at
5, 7, 10, 16, and 19 years.[25] A decrease of hypernasality was reported from 46% preoperatively at the age of 7
to 34% 2 years after DHPC. At 16 years, only 8% presented with hypernasal speech.
These results are more favorable than our data present, which could be explained by
a longer follow-up time or the functionally closed residual cleft in the hard palate
in 29% of patients before 5 years.
Kappen et al evaluated speech in after HPC at 33 months of age. At 20 years of age
still 38.6% of patients presented with hypernasal speech, compared with 58% hypernasality
rate after DHPC in our study cohort within a 15-month follow-up period.[26] Yet another study reports a 40% remaining hypernasal speech at 10 years of age following
a one-stage palatal closure at only 8 months.[27]
These results suggest that DHPC does not necessarily result in unfavorable speech
outcomes in terms of resonance. Since grimacing is a compensatory mechanism to reduce
nasal air loss, we could expect a decrease of this habit in time when resonance improves.
Reversing this habit would require awareness and training.
Articulation Errors
In 85% of patients, articulation errors were noted after HPC. These errors were classified
as only “present” or “absent,” even mild errors that occurred once during the assessment
were scored as being abnormal. This can overestimate the articulatory disturbances
that are clinically significant and notable during regular speech. No difference was
observed between the unilateral and bilateral group.
Adaption of compensatory errors occurs when refined articulation placement, such as
tongue tip placement is altered.[4] This could be due to the remaining cleft in the hard palate but could also occur
as a result of dental malocclusion, palatal morphology, and anatomical irregularity
of the palate and the alveolar ridge, more so in bilateral and larger defects, persisting
even after surgery.[28] This is particularly true for alveolar and interdental articulation.[28] In the current study, the amount and type of articulation errors were not specified,
and no records of dental occlusion were obtained; however, dental malocclusion is
known to be a consequence of CLAP.[29] Haque et al[29] and Kappen et al[26] both found a 44 to 45% dental malocclusion in their cohort of unilateral CLAP. The
demographic characteristics of our cohort are comparable to that in the latter Dutch
study, therefore dental malocclusion could also partially account for the high prevalence
of articulation disorders in our study.
Hortis-Dzierzbicka et al[27] assessed speech outcomes in 10-year-old children who were treated with one-stage
closure at 8 months of age and found that compensatory articulatory patterns were
present in only 4% of patients compared with 85% found in the current study. In the
report by Noordhoff et al and a follow-up paper 23 years later,[30]
[31] all patients who underwent HPC later than 4 years of age presented with increased
articulation errors, particularly those individuals with wide remaining cleft of the
hard palate.
These results support the hypothesis that compensatory articulation errors are present
in most patients with cleft palate and do not resolve immediately after HPC.[30] Although reversing these habits at a later age seem challenging, Lohmanderet al[25] reported a final decrease of articulation errors from 23% at 7 years to 6% at 10
years, 2 years after HPC. At 16 years of age, 96% of patients did not present any
articulation disorders. At 19 years of age, only one individual was diagnosed to have
mild articulation errors during speech. Additionally, Van Lierde et al[14] proved that postoperative speech therapy is essential to suppress or diminish the
adapted compensatory articulation patterns. After previous early one-stage palatal
closure or DHPC at 8 years of age, all patients had received at least 6 months of
speech training. None of the subjects of their study presented with compensatory articulation
disorders at 18 years.
Intelligibility
Resonance and the amount of articulation errors is reported to play a role in intelligibility
of speech.[14]
[25]
[26] Speech intelligibility increased from 35 to 71% (grade 1 and 2) during postoperative
follow-up in the current study.
In four patients postoperative intelligibility seemed to be decreased. One of these
patients had persistent hypernasality due to VPI which worsened over time and could
account for the deterioration of intelligibility. The results of this study support
a correlation between the decrease in hypernasal speech and the improvement in intelligibility,
in accordance with the previous literature.[14]
[26]
Lohmander et al reported an improvement of intelligible speech from 80% preoperatively
at 7 years to 98 to 100% intelligible speech at 10 years of age,[25] compared with the 84% reported intelligible speech following much earlier HPC at
36 months reported by Kappen et al.[26]
The literature indicates that timing of HPC is not the only factor contributing to
better speech outcomes. Prior surgical procedures, their timing, and maybe more importantly
sequential treatments such as adequate speech therapy combined with a good patient
compliance can also play a key role in improvement of speech and reduction of compensatory
mechanisms.[4]
[29]
[32]
[33]
Velopharyngeal Insufficiency
All patients in the current cohort underwent a soft palate closure between 9 and 11
months of age according to the Widmaier–Perko technique. This technique (Perko, 1979[34]) results in a full-thickness linear midline scar in the soft palate due to transient
ischemia of the periosteum followed by secondary epithelialization (Mommaerts, 2003[35]). This fibrotic tissue could potentially be the cause of reduced mobility of the
soft palate. Thirty-eight percent (18/48) of patients in this cohort were diagnosed
with VPI and opted for a surgical repair. The primary closure of soft palate could
partially account for persisting VPI weather or not confounded by a DHPC.
Strengths and Limitations
This study gives insight into changes in resonance and compensatory mechanisms in
speech after a two-stage palatoraphy including delayed closure of the hard palate
between the age of 8 and 13 years. This is one of the few studies reporting these
specific variables after HPC at the time of alveolar repair with the inclusion of
bilateral cases. There are obvious limitations; mainly the retrospective design of
the study and lack of data such as frequency and intensity of speech therapy. A longer
postoperative follow-up time would have given more insight into the further development
of articulatory changes following surgery. Furthermore, we included patients with
bilateral cleft known for its higher anatomical variability demanding different surgical
approaches. This might have impacted our results.
Future Perspectives
The current cleft treatment protocol at our institution follows a more individualized
approach to the timing of HPC. When the size of the defect of the hard palate technically
allows it, closure will be performed at an earlier age. We have implemented a patient-reported
set of outcome measurements, which includes patients' perspective of speech and psychosocial
health throughout the treatment trajectory until their discharge from follow-up at
the age of 22.[36]
[37] These data should give us more insight on the long-term patient-reported speech
outcomes after DHPC.
Conclusion
Based on the current speech outcome study in 48 patients with unilateral and bilateral
CLAP, a significant improvement was seen in resonance, degree of hypernasality and
intelligibility following a two-stage DHPC at the mean age of 10.5. However, habitual
compensatory pattern remained during the follow-up period. Our data combined with
previous literature suggest that treating ingrained compensatory errors does not only
rely on anatomical repair and its timing but that postoperative speech therapy is
crucial to reach optimal speech outcomes.
