INTRODUCTION
The necessity of expanding reliable knowledge
regarding speech development and surgical methods
is essential in providing care for children born with
cleft lip and palate [2].
Two important factors could affect the outcome
of cleft palate repair; the timing and the technique
of palatoplasty. It has long been recognized that
the best speech results are obtained when the palate
is repaired before the development of meaningful,
connected speech which also affected by the cognitive
development of the patient [3].
Cognitive dysfunction in children with clefts
of the lip and palate has been documented for
decades. Studies evaluating this issue reported that
children with non-syndromic clefts had lower IQs
[4].
It is important to recognize the relation between
the cognitive ability of the patient and its direct
relation with speech which will have a direct effect
on treatment of velopharyngeal dysfunction.
7
PATIENTS AND METHODS
This study was conducted upon 70 patient who
had cleft palate repair of different grades in Plastic
Surgery Department Assiut University Hospital.
It is a cross-sectional study data collected between
May 2016 to December 2018. We exclude patients
with other medical, mental diseases or syndromic
cases. Sample size was calculated using EPI info
2000 computer program taking percentage of occurrence
40%, worst acceptable result 50% and
confidence percentage 90%.
After collecting the standard history data, developmental
history and age of last palatoplasty.
we started with elementary diagnostic procedures
including auditory perceptual assessment. Videonasopharyngoscopy
and high-fidelity voice recording
as clinical diagnostic aid was done.
IQ test according Stanford-Binet Intelligence
scale IV [5]. Also CT scanning of the velopharyngeal
port, aerodynamics, and acoustic analysis was
done for some cases [6].
Treatment plan was chosen after considering
velopharyngeal closure type (coronal or sagittal
or circular) and velopharyngeal movement (palatal
movement and lateral pharyngeal wall movement).
The patients with adequate movement and small
velopharyngeal gap were candidate for speech
therapy (12 cases) and for the patients with large
or moderate velopharyngeal gap (6 cases).
We divided the patients according to the velopharyngeal
valve movements and velopharyngeal
closure into; patients with adequate lateral wall
movement and poor palatal movement (coronal
closure) who were candidate for pharyngeal flap
(4 cases), patients with adequate palatal movement
and poor lateral wall movement (sagittal closure)
were candidate for pharyngeal sphincteroplasty
(one case), patients with poor palatal and lateral
wall movement (circular closure) are candidate for
pharyngeal sphincteroplasty (one case).
Post-operative evaluation was done one month
after surgery to determine success and effectiveness
of surgery on patient's speech.
Data was collected and analyzed using SPSS
(Statistical Package for the Social Science, Version
20, IBM, and Armonk, New York).
Chi-square test was used to compare the nominal
data of different groups in the study while
student t-test and Mann-Whitney test was used in
case of not-normally distributed data.
RESULTS
Table (1) shows the baseline characteristics of
studied group. Mean age of all studied children
was 5.54±4.11 years with range between 2.5 and
21 years. Majority (71.4%) of studied patients had
cleft lip while ear, neonatal and prenatal problems
presented in 6 (8.6%), 6 (8.6%) and 2 (2.9%)
patients respectively.
Fifty (71.4%) patients had grade IV cleft palate,
8 (11.4%) had grade III, 10 (14.3%) had grade II
while only two patients had submucosal; cleft
palate. The age last palatoplasty ranged between
1 and 6 years with mean age was 2.12±1.24 years.
Median number of palatoplasty was one year with
range between one and there years.
8 Vol. 44, No. 1 / Relation between IQ & Velopharyngeal Dysfunction
Auditory perpetual assessment is shown at
(Table 2). Majority (88.9%) of patients with VPI
had open nasality and 2 (11.1%) patients had mixed
open and closed nasality. As regarding the degree
of nasality in those patients with VPI; slight, mild,
moderate and severe nasality presented in 8
(44.4%), 4 (22.2%), 2 (11.2%) and 4 (22.2%)
patients respectively.
Majority (55.6%) of patients with VPI had
moderate consonant imprecision while 46 (88.5%)
patients of those without VPI had normal consonant
precision. Only 5 (11.5%) patients of those without
VPI had glottal compensatory mechanism. Glottal,
pharyngeal and mixed compensatory articulation
presented in 6 (33.3%), 2 (11.1%) and 10 (55.6%)
patients respectively of those with VPI.
It was noticed that 16 (88.9%) of those with
VPI had audible nasal air escape and also, 8 (44.4%)
patients had facial grimace. As regarding overall
unintelligillity; 8 (15.4%) patients of those without
VPI had slight overall unintelligillity while 8
(44.4%), 4 (22.2%), 2 (11.1%) and 4 (22.2%)
patients with VPI had slight, mild, moderate and
severe overall unintelligillity. All parameters of
auditory perceptual assessment had significant
differences between both groups of patients.
Table (1): Baseline characteristics of studied group.
N=70
5.54±4.11
2.5-21
2 (2.9%)
6 (8.6%)
6 (8.6%)
50 (71.4%)
2 (2.9%)
10 (14.3%)
8 (11.4%)
50 (71.4%)
2.12±1.24
1-6
1 (1-3)
Age (years)
Range
History of:
Prenatal problem
Neonatal problem
Ear problem
Cleft lip
Grade of cleft palate:
Submucosal
Grade II
Grade III
Grade IV
Age of last palatoplasty (years)
Range
Number of palatoplasty
- Data was expressed in form mean (SD), median (range) and frequency
(percentage).
Table (2): Auditory perceptual assessment.
Without VPI
(n=52)
52 (100%)
00
52 (100%)
0000
46 (88.5%)
4 (7.7%)
2 (3.8%)
0
46 (88.5%)
6 (11.5%)
00
0
0
44 (84.6%)
8 (15.4%)
000
Nasality type:
None
Open
Mixed
Nasality degree:
Normal
Slight
Mild
Moderate
Severe
Consonant imprecision:
Normal
Slight
Mild
Moderate
Compensatory
articulation:
No
Glottal
Pharyngeal
Mixed
Audible nasal air escape
Facial grimace
Overall unintelligillity:
Normal
Slight
Mild
Moderate
Severe
- Data was expressed in form frequency (percentage). p-value was
significant if <0.05.
With VPI
(n=18)
0
16 (88.9%)
2 (11.1%)
0
8 (44.4%)
4 (22.2%)
2 (11.2%)
4 (22.2%)
2 (11.1%)
6 (33.3%)
0
10 (55.6%)
0
6 (33.3%)
2 (11.1%)
10 (55.6%)
16 (88.9%)
8 (44.4%)
0
8 (44.4%)
4 (22.2%)
2 (11.1%)
4 (22.2%)
pvalue
<0.001
<0.001
<0.001
<0.001
<0.001
<0.001
<0.001
Egypt, J. Plast. Reconstr. Surg., January 2020 9
Table (3) shows 80% of those patients without
VPI had average IQ but in case of those patients
with VPI; 6 (33.3%) patient had average IQ and
12 (66.6%) patient had below average IQ according
to Stanford-Binet Intelligence scale IV [5].
as regarding our study we found 34% of our cases
needed speech management.
We proved the direct relation between the age
of palatoplasty, IQ (cognitive ability) and the
occurrence of velopharyngeal dysfunction.
Recommendation:
The importance of applying the systemic speech
examination on repaired cleft palate patient.
Further comprehensive study to recognize IQ
effect on speech development on cleft palate patient.
Table (3): IQ.
Without VPI
(n=52)
4 (7.7%)
42 (80%)
6 (11.5%)
IQ:
Unknown
Average
Below average
With VPI
(n=18)
0
6 (33.3%)
12 (66.6%)
pvalue
<0.001
DISCUSSION
Velopharyngeal dysfunction results from inadequate
function of dynamic structures that work to
control the velopharyngeal sphincter formed by the
soft palate, the lateral pharyngeal walls, and the
posterior pharyngeal wall), which separates the
nasal cavity from the oral cavity during speech [7].
Dysfunction of this system may result in hypernasality,
nasal air emission, decreased intraoral air
pressure for oral pressure consonants, reduced
speech loudness, nostril or facial grimacing [8].
There are strong relationships between IQ and
language outcomes and between language skills
and speech perception ability [9] which agrees with
our study as 66% of patient with velopharyngeal
dysfunction has below average IQ.
Conrad et al., found that adult with non-syndromic
clefts of the lip and/or palate have a specific pattern
of cognitive deficits. Subjects with cleft were found
to have general IQ scores within the normal range,
but significantly below that of their matched controls
which agrees with our study [10].
Broen et al., [11] recognized the presence of
difference between cleft patient and others on two
developmental-cognitive measures administered
when the children were 24 and 30 months old and
on rate of vocabulary acquisition during their
second year. Which is a key observation which
affect the other IQ or speech development on cleft
patient.
In our study we proved that is direct relation
between cognitive ability of patient and incidence
of occurrence of velopharyngeal dysfunction. The
later affects the development of normal speech.
Conclusion and Recommendations:
At the end of our study we concluded the importance
of multidisciplinary team on management
of cleft palate patients specially speech pathologist
