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Purpose This study investigated the influence of the cleft type on the appearance of hypernasality after surgical maxillary advancement (MA). Methods Nasality was determined by measurement of nasalance (acoustic correlate of nasality) by nasometry. The study involved analysis of the nasalance scores of 17 individuals with isolated cleft palate (CP), 118 with unilateral cleft lip and palate (UCLP) and 69 with bilateral cleft lip and palate (BCLP), of both sexes, aged 18 to 28 years, after MA. Only individuals with normal nasalance scores indicating balanced resonance before MA were included in this study. Nasometry was performed 3 days before and 15 months after MA, on average. The proportion of patients who presented nasalance scores indicating hypernasality after surgery was calculated by the ANOVA test, and comparison among the different cleft types was evaluated by the chi-square test (p < 0.05). Results No significant difference was found in the proportions of individuals with hypernasality among the cleft types. Conclusion Nasometry showed that the appearance of hypernasality after MA in individuals with cleft palate with or without cleft lip occurred in similar proportions, regardless of the cleft type.

Purpose: To investigate the reliability in auditory-perceptual assessment of hypernasality of the Borg centiMax scale and the influence of the speech material on the reliability of two scales., Methods: Four experienced speech-language pathologists rated hypernasality of 80 audio recordings of patients with repaired cleft palate (40 single-word string and 40 sentences) using the 5-point ordinal scale and the Borg centiMax scale. Intra and inter-rater reliability were calculated for both scales and for both types of speech samples. The comparison between the agreement coefficients of the two speech samples was calculated using the Z test and between the scales was calculated by Spearman correlation coefficient, considering as significant p<0.05., Results: A very high and statistically significant correlation was found between the Borg centiMax scale and the ordinal scale for both speech samples. Intra- and inter-rater reliability was higher for Borg scale as compared to ordinal scale. Good to excellent intra-rater reliability was found for Borg scale for both speech samples. Poor to excellent intra-rater reliability was found for ordinal scale for both stimuli. Higher inter-rater reliability was demonstrated for Borg scale than ordinal scale for both speech samples. There was a significant difference between the single words string and sentences for intra- and inter-rater reliability using Borg scale, and for inter-rater reliability using ordinal scale., Conclusion: The Borg centiMax scale showed better intra and inter-rater reliability. Additionally, the speech material comprising of single words string showed better reliability in most of the comparisons for both scales.

Introduction A high agreement in the perceptual assessment of hypernasality among different listeners is difficult to achieve. Prior listener training and the standardization of analysis criteria may be effective strategies to decrease the effect of perceptual assessment subjectivity and increase the agreement among listeners. Objective To investigate the influence of prior training on agreement among different listeners in the perceptual assessment of hypernasality. Methods Three experienced speech-language pathologists analyzed 77 audio-recorded speech samples of individuals with repaired cleft palate. During the first phase, the listeners classified hypernasality according to their own criteria, using a 4-point scale. Seventy days later, they were required to complete the training to define the stimuli to be used as anchors for the assessment in the following phase. During the second phase, the listeners analyzed the same samples and rated hypernasality in a 4-point scale, using the anchors defined during training as the criteria. Intra- and interrater agreement in both the phases were calculated by the kappa coefficient. These values were statistically compared using the Z-test. Results The intrarater agreement obtained between the two phases of the study ranged from 0.38 to 0.92, with a statistically significant difference for one of the listeners (p=0.004). The agreement for the hypernasality degree obtained among the three listeners after training (0.54) was significantly higher than that obtained before training (0.37; p=0.044). Conclusion Listener training and the definition of criteria to rate hypernasality lead to the increase of intra- and interrater agreement.

Objective: To verify the influence of pharyngeal flap surgery on the management of velopharyngeal insufficiency on nasality and speech nasalance on nasal sound production in individuals with cleft lip and palate., Methods: Prospective study in 159 individuals with repaired cleft palate ± lip, of both genders, aged 6 to 57 years old. All the participants presented residual velopharyngeal insufficiency and were submitted to pharyngeal flap surgery. Perceptual speech evaluation and nasometric assessment were performed before and after (14 months on average) the pharyngeal flap surgery. Hyponasality was rated as absent or present, and nasalance scores were determined by means of nasometer using nasal stimuli, with a cutoff score of 43% used as the lowest limit of normality. Nasality and nasalance were compared before and after surgery (p < 0.05)., Results: On the basis of correlation between both the methods used, perceptual hyponasality was observed in 14% of the individuals, whereas nasalance scores indicating hyponasality (< 43%) were obtained in 25% of the patients after surgery., Conclusion: Pharyngeal flap surgery influenced the production of nasal sounds, causing hyponasality in a significant proportion of individuals. The presence of this speech symptom can also be an indicator of upper airway obstruction caused by pharyngeal flap, which should be investigated objectively and prudently postoperatively.

Purpose: To analyze the velopharyngeal (VP) activity of subjects with velopharyngeal dysfunction (VPD) by acoustic rhinometry, as compared to rhinomanometry., Methods: This was a prospective clinical study conducted in 41 adults, both genders, with repaired cleft palate, with or without a previously repaired cleft lip, and residual VPD on clinical assessment, without compensatory articulations for [p], [t], and [k]. The outcome measures were as follows: (1) on acoustic rhinometry, nasopharyngeal volumetric change (ΔV) during [p], [t], and [k], relatively to rest condition (decreases by <3 cm3 considered as absence of VP activity); (2) on modified anterior rhinomanometry, VP orifice area (areas ≥0.05 cm2 considered as inadequate closure). The plosive [p] was used when comparing the techniques (n=24)., Results: (1) A mean ΔV decrease of 18% was observed during [k], which was significantly lower (p<0.05) than the decrease reported for individuals without VPD (30%). ΔV values suggesting VPD were observed in 59% subjects. Similar results were obtained for [p] and [t], which shall be used as stimulus, given that they do not involve the use of the tongue to lift the velum during VP closure, differently from the velar plosive [k]. (2) Inadequate closure was seen in 85% subjects. No correlation was observed between ∆V and VP orifice area. Agreement between techniques was observed in 51% cases., Conclusion: Acoustic rhinometry had low accuracy as a diagnostic method of VPD when compared to the gold standard method. Nevertheless, the technique shows potential as a method for monitoring the outcomes of clinical and surgical treatment of VPD aimed at increasing velar and pharyngeal activity.

Purpose: To investigate the correlation among velopharyngeal closure, hypernasality, audible nasal air emission (NAE) and nasal rustle (NR), in individuals with repaired cleft palate., Methods: One hundred patients with repaired cleft palate and lip, submitted to pressure-flow study for measurement of velopharyngeal orifice area (velopharyngeal area) and speech sample recordings. Velopharyngeal area was estimated during the production of the sound /p/ inserted in a sentence, and the velopharyngeal closure was classified as adequate, borderline or inadequate. Hypernasality was rated using a 4-point scale, NAE and NR were rated as absent or present, by three speech language pathologists, using recorded speech samples. Inter and intra-judge agreements were established. Statistical analysis was performed using the Spearman correlation coefficient considering p<0.05. An ordinal logistic regression model was developed to investigate whether the characteristics of speech can predict velopharyngeal closure. For this, the speech samples included in this analysis were those that obtained 100% agreement among raters as to the degree of hypernasality (43 out of 100)., Results: Significant correlation was found between hypernasality and velopharyngeal area; audible NAE and velopharyngeal area. A negative correlation was observed between the NR and velopharyngeal area. The regression analysis showed that the perceptual speech characteristics contributed significantly to predict the velopharyngeal closure., Conclusion: There is significant correlation between velopharyngeal closure and hypernasality, NAE and NR. It suggests that the perceptual speech characteristics can predict velopharyngeal closure, favoring the diagnosis and the definition of treatment conduct of velopharyngeal dysfunction.

Purpose: This study obtained nasalance scores during use of compensatory articulation (CA) and compared nasalance between groups with and without hypernasality and with and without CA., Methods: Speech samples were obtained from 43 individuals with and without velopharyngeal dysfunction during repetition of 20 phrases originating 860 audio recordings and their respective nasometric values. After excluding 143 recordings due to low quality, the remaining 717 samples were rated by three speech language pathologists (SLPs), independently, for presence or absence of hypernasality and CA. Nasalance scores for the 553 samples rated with 100% agreement among the SLPs were grouped according to the auditory-perceptual ratings: Group 1 (G1) - included samples without hypernasality and without CA (n=191); Group2 (G2) - included samples with hypernasality and without CA (n=288); Group 3 (G3) - included samples with hypernasality and with pharyngeal fricative (n=33); Group 4 (G4) - included samples with hypernasality and with glottal stop (n=41)., Results: Analysis of variance (ANOVA) revealed significant difference nasalance scores which were significantly higher for G2, G3, and G4 (p<0.0001) when compared to G1. The use of pharyngeal fricative (G3), particularly during /f/ (p=0.0018) and /s/ (p=0.0017) productions resulted in nasalance scores significantly higher than scores found for G2., Conclusion: Significantly higher nasalance values where identified during use of pharyngeal fricative.

Purpose: To investigate the postoperative outcomes of pharyngeal flap surgery (PF) and secondary palatoplasty with intravelar veloplasty (IV) in the velopharyngeal insufficiency management regarding nasalance scores and velopharyngeal area., Methods: Seventy-eight patients with cleft palate±lips submitted to surgical treatment for velopharyngeal insufficiency, for 14 months on an average, were evaluated: 40 with PF and 38 with IV, of both genders, aged between 6 and 52 years old. Hypernasality was estimated by means of nasalance scores obtained by nasometry with a cutoff score of 27%. The measurement of velopharyngeal orifice area was provided by the pressure-flow technique and velopharyngeal closure was classified as: adequate (0.000-0.049 cm²), adequate/borderline (0.050-0.099 cm²), borderline/inadequate (0.100-0.199 cm²), and inadequate (≥0.200 cm²)., Results: Absence of hypernasality was observed in 70% of the cases and adequate velopharyngeal closure was observed in 80% of the cases, in the PF group. In the IV group, absence of hypernasality was observed in 34% and adequate velopharyngeal closure was observed in 50% of the patients. Statistically significant differences were obtained between the two techniques for both evaluations., Conclusion: PF was more efficient than the secondary palatoplasty with IV to reduce hypernasality and get adequate velopharyngeal closure.