Longitudinal Evaluation of Articulation and Velopharyngeal Competence of Patients with Pharyngeal Flaps D. R. Van Demark, PH.D. M. A. Harpin, PH.D. In this study, 129 patients with cleft palate who had pharyngeal flaps were evaluated longitudinally. Articulation scores improved ap- proximately 15 percent following surgery, and by age 16 the majority of subjects achieved velopharyngeal competence and 90 percent cor- rect articulation. The findings also demonstrated that the risk of re- quiring secondary management increased with the severity of the cleft. In addition, a higher percentage of patients who had received a pri- mary Von Langenbeck procedure required secondary management than did patients who had the Wardill primary palatoplasty. Age at time of the pharyngeal flap operation did not emerge as a critical factor in speech outcome. It is generally reported that the pharyn- geal flap operation successfully improves articulation and establishes velopharyn- geal competence for approximately 80 percentof patients. At present, however, very little is known about the factors re- lated to the success of the procedure. In an early study, Moll et al (1963) found that pharyngeal flap width and the patient's age at time of secondary operation were re- lated to the success of the pharyngeal flap operation. More recently, Riski (1979) re- ported that patients who received pharyn- geal flaps prior to 6 years of age demon- strated more rapid improvement in articulation and resonance balance than did children who received a pharyngeal flap after age 6. In contrast, Van Demark and Hammer- Dr. Van Demark is a Professor in the Department of Otolaryngology-Head and Neck Surgery and De- partment of Speech Pathology and Audiology at the University of Iowa, Iowa City, IA. Dr. Hardin is an Assistant Professor in the Department of Commu- nication Sciences and Disorders at the University of Montana, Missoula, MT. _ This paper was presented at the Annual Meeting of the American Cleft Palate Association, Seattle, Washington, May 24, 1984, and was supported in part by Public Health Service Grant no. DE-00853, Na- tional Institute of Dental Research. quist (1978) found that early secondary management (performed before 4 years of age) was not associated with better artic- ulation proficiency or velopharyngeal competence. However, when secondary management was delayed until after 10 years of age, there was also a trend for poorer articulation. When compared at age 10, subjects who received a pharyngeal flap prior to 5 years of age were given poorer velopharyngeal competence ratings than subjects who received secondary manage- ment after 5 years of age. Van Demark and Hammerquist concluded that the optimal time of secondary management was be- tween 4 and 10 years of age. Although the primary objective of their study was to ex- amine the relationship between the timing of the pharyngeal flap operation and the success of the technique, Van Demark and Hammerquist also noted that type of cleft and type of palatoplasty appeared to be risk factors associated with the need for sec- ondary management. According to the au- thors, subjects with cleft of the soft palate only, required a pharyngeal flap operation less frequently than subjects with more se- vere types of cleft. However, Riski's (1979) data indicated little difference in types of cleft that needed secondary management. Additional research is needed to iden- 163
10
Embed
Longitudinal Evaluation ofArticulation and Velopharyngeal ...
This document is posted to help you gain knowledge. Please leave a comment to let me know what you think about it! Share it to your friends and learn new things together.
Transcript
Longitudinal Evaluation of Articulation and Velopharyngeal
Competence of Patients with Pharyngeal Flaps
D. R. Van Demark, PH.D.
M. A. Harpin, PH.D.
In this study, 129 patients with cleft palate who had pharyngeal
flaps were evaluated longitudinally. Articulation scores improved ap-proximately 15 percent following surgery, and by age 16 the majorityof subjects achieved velopharyngeal competence and 90 percent cor-rect articulation. The findings also demonstrated that the risk of re-
quiring secondary management increased with the severity of the cleft.In addition, a higher percentage of patients who had received a pri-
mary Von Langenbeck procedure required secondary managementthan did patients who had the Wardill primary palatoplasty. Age attime of the pharyngeal flap operation did not emerge as a critical
factor in speech outcome.
It is generally reported that the pharyn-
geal flap operation successfully improves
articulation and establishes velopharyn-
geal competence for approximately 80
percentof patients. At present, however,
very little is known about the factors re-
lated to the success of the procedure. In
an early study, Moll et al (1963) found that
pharyngeal flap width and the patient's age
at time of secondary operation were re-
lated to the success of the pharyngeal flap
operation. More recently, Riski (1979) re-
ported that patients who received pharyn-
geal flaps prior to 6 years of age demon-
strated more rapid improvement in
articulation and resonance balance than did
children who received a pharyngeal flap
after age 6.
In contrast, Van Demark and Hammer-
Dr. Van Demark is a Professor in the Departmentof Otolaryngology-Head and Neck Surgery and De-partment of Speech Pathology and Audiology at theUniversity of Iowa, Iowa City, IA. Dr. Hardin is anAssistant Professor in the Department of Commu-nication Sciences and Disorders at the University ofMontana, Missoula, MT. _
This paper was presented at the Annual Meeting
of the American Cleft Palate Association, Seattle,
Washington, May 24, 1984, and was supported in part
by Public Health Service Grant no. DE-00853, Na-
tional Institute of Dental Research.
quist (1978) found that early secondary
management (performed before 4 years of
age) was not associated with better artic-
ulation proficiency or velopharyngeal
competence. However, when secondary
management was delayed until after 10
years of age, there was also a trend for
poorer articulation. When compared at age
10, subjects who received a pharyngeal flap
prior to 5 years of age were given poorer
velopharyngeal competence ratings than
subjects who received secondary manage-
ment after 5 years of age. Van Demark and
Hammerquist concluded that the optimal
time of secondary management was be-
tween 4 and 10 years of age. Although the
primary objective of their study was to ex-
amine the relationship between the timing
of the pharyngeal flap operation and the
success of the technique, Van Demark and
Hammerquist also noted that type of cleft
and type of palatoplasty appeared to be risk
factors associated with the need for sec-
ondary management. According to the au-
thors, subjects with cleft of the soft palate
only, required a pharyngeal flap operation
less frequently than subjects with more se-
vere types of cleft. However, Riski's (1979)
data indicated little difference in types of
cleft that needed secondary management.
Additional research is needed to iden-
163
164
tify those factors that are related to the
success of the pharyngeal flap technique.
Further study is also needed to identify
those factors that may increase the need
for secondary management. The purposes
of this study were to examine the longi-
tudinal development of articulation, na-
sality, and velopharyngeal competence of
a group of subjects with cleft palate who
had undergone the pharyngeal flap op-
eration and had participated in the Iowa
Cleft Palate Longitudinal Research Proj-
ect.
Specifically, the data, although neces-
sarily retrospective in nature, could pro-
vide some insight into the following ques-
tions:
1) Does the age of initial palatoplasty
appear to relate to the need of sec-
ondary management and speech re-
sults? »Does the type of initial palatoplastyappear to relate to the need of sec-ondary management and speech re-sults?Does the type of cleft appear to re-late to the need of secondary man-agement and speech results?Does the age of pharyngeal flap sec-ondary management relate to speechresults?
2)
3)
4)
PROCEDURE
Subjects
All subjects in this study were part of theIowa Cleft Palate Longitudinal Project.Initially, subjects were enrolled in theproject when treatment was needed; how-ever, after 1963 subjects were enrolled inthelongitudinal project at birth. Approx-
Cleft Palate Journal, July 1985, Vol. 22 No. 3
imately 520 subjects have been enrolled in-the project, which includes computer stor-age of pertinent speech-articulation dataand information about various types ofphysical management.
All subjects who had a secondary palatalprocedure, which in this case was a supe-riorly-based pharyngeal flap operation,were identified from the computer iden-tification program. A total of 129 subjectswere available for study. Subjects' birth-dates ranged from 1946 to 1975, with themean year of birth, 1963.
Information about the type of cleft andtype of palatal operation for these subjectsis shown in Table 1. Eleven of the 129subjects had cleft of the soft palate only,28 had cleft of the hard and soft palate,58 had unilateral cleft of the lip and pal-ate, and 32 had bilateral cleft of the lip andpalate. As shown, the majority of subjectsreceived either the Von Langenbeck orWardill procedure for surgical repair ofthe palate. Timing of palatoplasty rangedfrom 3 months to 9 years of age, with amean age of 3 years. Age of secondarymanagement ranged from 2 years, 5months to 16 years, 2 months, with a meanage of pharyngeal flap management of 7years, 2 months.
DATA COLLECTION
Annual articulation test scores, obtainedwith the 105-item articulation test used inthe research protocol, were retrieved foreach subject using the computer programdescribed previously by Van Demark andTharp (1973). This test includes the IowaPressure Articulation Test, the Templin-Darley Screening Test of Articulation, aswell as other phonemes in various word
TABLE 1. Subjects Categorized According to Cleft Type and Type of Primary Palatoplasty Type of Cleft Male Female N Type of Surgery N
Soft Palate Only (including subjectswith submucous) 1 10 11 l-stage Von Langenbeck 49
Hard and Soft Palate 8 20 28 2-stage Von Langenbeck 14Unilateral Lip and Palate 35 23 58 Wardill (NVB®* intact) 37Bilateral Lip and Palate 25 7 32 Wardill (NVB* severed) 24
Other 5 *NVB = neurovascular bundle
Van Demark and Hardin, LONGITUDINAL EVALUATION
positions. A total of 1506 articulation tests
for the 129 subjects was available for study.
Clinical ratings of velopharyngeal com-
petence assigned by the examining speech
pathologist during each examination were
also retrieved. These clinical ratings (com-
petence, marginal competence, or incom-
petence) were made by the speech pa-
thologist as the best estimate of the
adequacy of the mechanism. Routinely,
these ratings were based on a combination
of observations including conversational
speech, word, and sentence articulation
testing, stimulability, examination of the
oral mechanism, and for some patients,
information obtained from lateral x-ray
films and fluoroscopy. Parental reports and
reports from speech clinicians working with
the child locally were considered in the
composite rating. In addition, severity rat-
ings (7 point scales where 1 = normal and
7 = severe) of nasality and articulation de-
fectiveness in connected speech were re-
trieved.
Approximately 90 percent of the obser-
vations obtained from the longitudinal
project were made by two speech pathol-
ogists who were experienced in evaluating
the speech of children with cleft palate.
Estimates of their current interreliability
in articulation test scoring and severity
ratings of articulation and nasality were
obtained in a recent report (Hardin, 1984).
Agreement between the two examiners in
scoring articulation tests was high (84%).
Interjudge reliability of severity ratings was
also relatively high with ratings exact or
within one scale value on 92 percent (ar-
ticulation) and 84 percent (nasality) of the
samples. An estimate of their interjudge
reliability in assigning clinical judgments
of velopharyngeal competence was ob-
tained in an earlier study (Morris, 1978),
and 84 percent agreement was reported.
RESULTS
The articulation test scores were exam-
ined prior to and following the pharyn-
geal flap operation. As demonstrated in
Table 2, the articulation scores before sec-
ondary management were poor. Subjects
between the ages of 4"/;, and 8 years im-
165
proved their articulation scores by ap-
proximately 15 percent (average differ-
ence in pre and post scores) following
secondary management. After age 8, the
articulation test scores of the pre- and post-
pharyngeal flap groups were more simi-
lar. It should be noted that the number of
subjects gets smaller across age levels for
the pre-flap group because as age in-
creases, more subjects received pharyn-
geal flaps. Conversely, for the post-flap
group the number of subjects becomes
larger because additional subjects had
pharyngeal flap operations at each age level
studied. Although some individual sub-
jects achieved relatively high articulation
scores, the group data indicate that the ar-
ticulation performance of these subjects was
well below that expected of 8-year-old
children without clefts and slightly below
the norms of children with clefts (Van De-
mark et al, 1979).
The most frequent error types observed
prior to secondary management included
omissions, sound substitutions, and nasal
distortion of consonant sounds (Table 3).
_ Although the number of errors related to
omissions and substitutions decreased with
age, nasal distortion errors did not. Anal-
ysis of the data following pharyngeal flap
management revealed a substantial de-
crease in articulation errors related to na-
TABLE 2. Mean Percentage of Elements Correct
on the 105-Item Iowa Articulation Test Prior toand Following the Pharyngeal Flap Operation
TABLE 6. Mean Percentage of Total Elements Correct on the 105-Item Iowa Articulation TestFollowing the Pharyngeal Flap Operation for Subjects grouped According to Cleft Type.
SPO = soft palate only, H&SP = hard and soft palate, ULP = unilateral lip and palate and BLP = bilateral
lip and palate
168 Cleft Palate Journal, July 1985, Vol. 22 No. 3
TABLE 7. Mean Percentage of Elements Correct on the 105-Item Iowa Articulation Test for allSubjects Grouped According to Age at Time of Pharyngeal Flap Operation
BAarpACH J, MoRRIS HL, OLn WH, McDERMOTT-Murray J, Moony MS, BARDACH E. Late resultsof multidisciplinary management of unilateral cleftlip and palate. Ann Plast Surg 1984; 12:235.
172 Cleft Palate Journal, July 1985, Vol. 22 No. 3
HARDIN MA. The contribution of selected variablesto the prediction of speech proficiency for adoles-cents with unilateral cleft of the lip and palate. Ph.D.Thesis, Iowa City: University of Iowa, 1984.
MoLL KR, HUrFMAN WC, LIiErRLE DM, SMITH JK.Factors related to the success of pharyngeal flapprocedures. Plast Reconstr Surg 1963; 32:581.
MORRIS HL. Velopharyngeal competence and theDemjen W/V-Y technique: In: Morris HL, ed. TheBratislava project. Iowa City: University of IowaPress, 1978. - .
RiskI JE. Articulation skills and oral-nasal resonance
in children with pharyngeal flaps. Cleft Palate J1979; 16:421.
Van DEMARK DR, THARP R. A computer programfor articulation tests. Cleft Palate J 1973; 10:378.
Van DEMARK DR, HAMMERQUIST PJ. Longitudinalevaluation of articulation and velopharyngeal com-petency of patients with pharyngoplasties. A paperpresented to the American Cleft Palate Associa-tion, Atlanta, Georgia, 1978.
VAN DEMARK DR, MORRIS HL, VANDEHAAR C. Pat-terns of articulation abilities in speakers with cleftpalate. Cleft Palate J 1979; 16:200.