The cleft palate

Cleft Lip and/or Cleft Palate:

In 1928, William Edward Mandall Wardill described cleft palate as "one of the rare cases of perfect speech result." Conversely, today, it is referred to as one of the most frequent birth malformation caused by atypical facial growth of a foetus during the initial stages of gestation affecting the upper lip and roof of the mouth (the palate). Clefting happens when tissues forming the upper lip and/or the palate do not align properly; and this may affect other parts of the face as well. Shprintzen et al., (1985) reported that 40% of all cleft infants have associated malformations. As children naturally differ, the condition of the clefting also varies from child to child and can range from a small notch in the lip to an opening running into the palate and nose. Some studies described children with cleft palate as maladjusted (Billing, 1951), and as having other emotional and intellectual problems. Moreover, a number of studies (e.g. Goodstein, 1961; May, and Munsons 1955) indicated that there is some relationship between cleft palate and intellectual impairment. Though, among children cleft palate, a mild to moderate degree of intellectual disorder has been noted, the impairment is more of verbal rather than intellectual (Pannbacker, 1971). Further, studies (Hackbush, 1951; Palmer, 1962; Sidney, 1956; Watson, 1964) have reported that although these children may have some difficulties in social acceptance, they are normally not maladjusted or emotionally disturbed.

In the literature, clefts have been classified differently based on different anatomical and morphological features. Davis & Ritchie (1922) divided clefts into three types on the basis of the position of the cleft in relation to the alveolar process. The first type, according to this classification, is labelled as prealveolar clefts, median, unilateral or bilateral; the second one that involves only the soft palate or the soft and hard palates is referred to as postalveolar clefts or a submucous cleft; and the third one as an alveolar clefts, median, unilateral or bilateral. Another classification by Veau (1931) (as sited by Converse et al., 1977), considering the incisive foramen as a point of reference, categorises them into four types. These are, cleft of the soft palate only; cleft of the hard and soft palate that involves only the secondary palate; complete unilateral cleft that extends from the uvula to the incisive foramen in the midline and deviates to one side and usually extending through the alveolus at the side of the future lateral incisor tooth; and complete bilateral cleft, that resembles complete unilateral with two clefts running from the incisive foramen through the alveolus. When both clefts involve the alveolus, the premaxilla remains suspended from the nasal septum. In 1958, Kernahan and Stark (1958) came up another classification based on embryology. They proposed two types of clefts, that is, primary and secondary clefts, the incisive foramen being the dividing line between them. Following Kernahan & Stark (1958), Harkins et al., (1962) provided a more elaborate classification of clefts, which is presented below as it is modified and simplified by Spina (1974).

Group I: Preincisive foramen clefts (clefts lying anterior to the incisive foramen), that is, clefts of the lip with or without an alveolar cleft.

  1. Unilateral
  2. Bilateral
  3. Median

Group II: Transincisive foramen clefts (clefts of the lip, alveolus, and palate).

  1. Unilateral
  2. Bilateral

Group III: Postincisive foramen clefts

Group IV: Rare facial clefts

Tessier (1976) came up with another taxonomy, which was considered the most logical and advanced classification system which is still being used universally (Tiwari et al., 1991, Wenbin et al., 2007). Below are the four types of clefts suggested by Tessier (1976).

  • Uni-lateral or bi-lateral
  • Complete, incomplete or micro-form (e.g., sub-mucous cleft palate)
  • Clefting of the lip with or without the palate, or of the palate in isolation
  • Atypical cranio-facial clefts

A cleft of the hard palate can be due to a sever clefting of the lip, but they are distinct (Emily et al., 2005) because their origins of defect are different (Fogh-Andersen, 1942; Fraser & Calnan, 1961) as only the primary palate malformation causes lip clefting while cleft palate arises from both primary and secondary palates defects (Kreiborg & Hermann, 2002). Based on some variables, cleft palate without a cleft lip is often considered to be different etiologically from cleft lip in the presence or absence of cleft palate. Nonetheless, it has been suggested that cleft lip and palate and cleft lip without cleft palate have generally been regarded as variations of the same malformation, differing only in severity (Mitchell et al., 2002). Clefts of lip and/or palate may cause a delay in speech development, articulation and voice problems, other defects such as abnormal teeth growth due to dental problems, ear infections and hearing problems, and other developmental problems that affect language, hearing, feeding and social development. The problem of hearing also apparently affects speech production. The problem involves the high incidence of middle ear effusion and conductive hearing loss as well as the effect of dentition associated errors (Vallino & Thompson, 1993).

Clefting is observed more commonly in Asia (1 to 2 in 1000) than in Africa and America (0.5 to 1 in 1000) (Shapira et al., 1999; Mossey & Little, 2002; Murray, 2002). Moreover, some studies (e.g., Vanderas, 1987) indicated that the occurrence of clefting varies based on ethnic background, sex, the type of clefting (Vanderas, 1987). According to type of cleft, Fogh-Andersen (1942) reported that 50% of clefts is cleft lip and palate, 25% isolated cleft palate, and 25% cleft lip alone; and men are more vulnerable to cleft lip and palate than to isolated cleft palate, which is more prevalent in women than cleft lip and palate (Converse et al., 1977, Fogh-Andersen, 1942; Fraser & Calnan, 1961). The left-sided cleft lip is generally claimed to be the most common one (Fogh-Andersen, 1942; Fraser & Calnan, 1961; Wilson, 1972)

Earliest historical information about cleft lip and/or palate is based on a combination of religion, superstition, invention and charlatanism (Bhattacharya, 2009). In ancient times, in many cultures, clefting and many other congenital defects were most associated with bad fortune or spirit, which in many cases would result in abandonment or even death of the affected children. Although there had already been suggestion by ancient scholars about embryological basis of clefting, Frederick Blandin (1838-96) was the one who suggested the most compelling account of how clefting occurs by describing the failure of the premaxilla and the maxillary segments to come together (Blandin, 1937, as cited in Bhattacharya, 2009). Even to date, in most cases, definitive answers as to what causes different types of cleft lip and/or palate have not yet been put forward. More than 300 syndromes have already been associated with clefting (Murray, 2002; Mossey & Little, 2002); and recent researches have been more indicative of the root cause of clefting than ever before. Most of these studies (the ones carried out on animals included) suggest that most of the cases are caused by multiple genetic and environmental factors. Moreover, Fraser & Pembrey (1979) noted that 70% of clefting is caused by the interaction of multiple genetic and environmental factors, and are not part of an identifiable syndrome.

The practice of repairing clefting goes back to 390 BC, when a Chinese physician managed to close cleft lip successfully (Morse, 1934; Perko, 1986; Long, 1936). Most of the earlier attempts at cleft palate repair focused on the anatomical closer of the cleft, often with some problems in terms of facial growth, dentition, and speech (Grunwell, et al., 1993; Harding, et al., 1993). More recently, with the advancement of surgical equipments and techniques, remarkable developments in terms of anatomical and functional results have been achieved. However, in spite of what have been attained the years, there are issues that have still remained unresolved. The technique and timing of cleft repair are the most controversial variables in the evaluation of outcomes of a surgery. Different surgical managements result in difference in outcomes, which generally makes assessment of results difficult and probably impossible. There has also been and continues to be variation in the timing of cleft palate repair, making the management of the problem tricky. Recommendations on the optimal timing of cleft palate repair range from a time as early as soon after birth (Jolley, 1954) to as late as 13 years (Schweckendiek, 1978).

Some surgeons prefer to repair the palate in two stages; others recommend operating the lips and the palate one after the other, with a considerable time gap in between. The central problem about the timing of palate repair is said to be due to the trade-off between speech outcome and facial growth. It has been suggested that the earlier the hard palate repair the better the speech development becomes, but facial growth would be in a greater risk; conversely, later repair is said to favour facial growth, but normal speech development would be in compromise (Harding, et al., 1993, Roberts et al., 1991). However, Williams & Sandy (2003) reported that timing of primary palate repair and maxillary growth are unrelated; and, nowadays, it is generally understood that the main objective of repairing cleft lip and/or palate is to make speech production easier (D?Antonio & Nagarajan, 2003; Sharp, 2003). This, in a way, favours the idea that the repair needs to be carried out in early childhood as it is apparent that, if at all palate repair and maxillary growth are somehow related, consequences of speech compromises in early childhood would be more severe later on than the consequences of maxillary ones; and compromises on speech in the early years might be more difficult to correct later on than the ones on maxillary.

Speech Development

Considerable interest in studying prespeech vocalizations has been shown since the 1980s (Salas-Provance et al., 2003) as it became apparent that prespeech behaviours are essential to later speech. Although it is common for children who are born with cleft palate to have speech defects at some point in their lives, but this is not always the case. In many of them, speech develops without any therapy particularly in those with cleft lips. About 40% of children born with cleft palate have longstanding problems resulting in speech deficits (Stengelhofen, 1989), indicating the need for continuous professional involvement in cleft palate speech assessment and management (Sara, 1993; Harding & Grunwell, 1996). In those with speech development problems, the defect is mostly both in terms of quantity and quality (Ball, 1989; Sunitha et al., 2004; Scherer et al., 1999). In normal children, universally, there is a huge similarity between the phonetic inventory of babbling and the rudimentary sound system of a child's language (Locke, 1983; Ferguson, et al. 1992); and it can be assumed that similar relationship exist in children with cleft palate as some features of prespeech vocalization of children with cleft palate and their later speech have some similarities (Westlake & Rutherford, 1966). In the past, such a hypothesis would sound implausible because, for many years, it was believed, that prespeech productions were not affected by cleft palate (Jones & Hardin-Jones, 2002) and hence later cleft palate speech would not be discernible in the prespeech productions. In contrast, later studies on speech developments in children with cleft palate indicated a delay in the onset of babbling (Van Demark et al., 1979; Westlake & Rutherford, 1966; Ross & Johnston, 1978; Grunwell & Russel, 1987) and other speech defects like a tendency of back articulation which usually persist into later speech. Furthermore, based on longitudinal studies of the relationship between prespeech vocalization and later speech and language performance in cleft children, Chapman et al., (2003) and Chapman, (2004) note that children with more consonants and more stops in babbling have better speech and language performances by the age of 3.

Since all children in early childhood have immature vocal tract and intraoral mechanism that impact the production of several speech sounds, considering prespeech productions in children with cleft palate is rather difficult particularly in the absence of documented stages of typical speech development. As a result, many studies examine early speech developments of children with cleft palate in comparison with those in non-cleft children, mainly not to rule out the speech defects caused by the cleft palate. Such comparative studies have described differences and similarities of different aspects of early speech productions and developments in non-cleft children and in those with cleft palate. Scherer et al., (2000), for example, showed that, at 6 months of age, the two groups of children (i.e., babies with and without cleft palate) exhibited more similarities than differences in prespeech productions, but later at 9 months of age, for babies with cleft palate, delays in babbling were observed; and by 12 months of age, a significant difference in babbling was observed. Chapman (1991) also noted reduplicated and variegated babbling patterns in 12-month-old babies with cleft palate but not in their non-cleft peers. In addition to a delay in babbling, several studies on early language development (Olson, 1995; Broen et al., 1998; Scherer et al., 1999) show that cleft children show a delay in onset of first words and early expressive vocabulary development as well. Some studies (e.g., Vihman et al., 1985) pointed out that first words of cleft babies contain those sounds heard during babbling. Further, Estrem and Broen (1989) indicated that cleft children selected words based on phonological features; and, compared to non-cleft children, cleft children produced more words starting with plosives and apical sounds; and tended to attempt more words beginning with nasals, glides, approximants and vowels. If prespeech develops in a delayed way, then it is likely that articulation problems occur as well. In addition, studies on early phonological development of children with cleft palate noted a delayed (Chapman & Hardin, 1992; Chapman, 1993) and disordered phonological processes in cleft population (Harding & Grunwell, 1995).


In terms of articulation, the type and severity of cleft and the resulting speech defects are apparently related. Further, some studies (e.g. Spriestersbach, et al., 1961; Morris, 1962) claim that children with cleft lip and palate have better articulation than those with cleft palate only. Conversely, Bryne, et al., (1961) states that those with cleft palate only have better articulation than those with cleft lip and palate; and Counihan, (1956), as cited by Riski & Delong (1984), found no difference in articulation between the two groups. Since a large association appears to exist between articulation problems and the part of clefting, some level of articulation differences among the different types of clefting is inevitable. Moreover, some group of speech sounds are more valuable in a certain cleft type than in anther. In cleft palate speech, for example, certain types of consonants such as plosives, fricatives and affricates are particularly susceptible to misarticulation as a consequence of the cleft palate condition (Brndsted et al., 1994); because for these groups of consonants to be correctly realized, the velo-pharyngeal port/sphincter should be closed which is not the case as a result of cleft palate. Further, according to Subtelny & Subtelny (1959) calculations of the frequency of errors in different consonant productions of adults with cleft palate, /s/ and /z/ appeared to be the most frequently distorted, followed by /p/and /b/; /f/ and /v/; /k/ and /?/; /t/ and /d/; /?/ and /r/. In addition, unlike normal pattern, some articulatory features frequently appear before others. O'Gara & Logemann (1988) noted that in, cleft palate speech, voiceless plosives frequently occur before voiced plosives, a converse pattern compared to normal development. Likewise, in typical development, initial fricatives are generally acquired after final fricatives (Ferguson, 1978); whereas in the children with cleft palate, acquisition of fricatives may be approached from an idiosyncratic pattern of stop acquisition (Harding & Grunwell, 1996). Stengelhofen (1989) summarizes the potential renege of articulatory problems related to cleft palate.

  • changes in breath direction;
  • inadequacy of breath support because of air waste;
  • weakened fricatives, plosives and affricates;
  • audible nasal emission;
  • tendency for contacts to be towards the back of the oral cavity;
  • preponderance of laminal contacts and imprecise tongue tip movements;
  • use of double articulations;
  • secondary articulations such as pharyngealization, velarization;
  • frequent use of glottal stop;
  • fricatives may be retracted in place to become velar, pharyngeal or glottal.

Normally, one of the defining features of speech segments is the source and direction of airstream used for them to be produced. Different types of consonants use airstream differing in terms of source and/or direction. Changes in breath direction would distort target sounds or result in the production of another sound. In cleft palate speech, due to the cleft palate, for all pressure consonants, i.e., glottal stops, nasalized plosives, pharyngeal plosives, pharyngeal fricatives or posterior nasal fricatives, the air which is supposed to pass through the oral cavity changes its direction and inappropriately escape into or through the nasal cavity, resulting in inadequacy of breath support and hence weak articulation of most oral sounds. This does not happen with vowels as they do not involve a build-up of air pressure. The inappropriate air escape would make audible nasal emission, triggering inapt compensatory articulatory habits, which happen, it is argued, when individuals with cleft palate, consciously or unconsciously, try to avoid or to cover up nasal emission (Howard, 2004). The compensation strategy is generally meant to maximize the range of meaningful contrasts among sounds (Harding & Grunwell, 1998). Compensatory articulatory habits include using a very soft voice that uses less breath pressure, weakly articulated consonants, retracted articulations, double articulations, lateralized articulations, and fricative gliding (Morley, 1970; Hutters & Brondsted, 1987; Harding & Grunwell, 1998). Such strategies aiming at substituting target consonants are referred to as active cleft-type speech characteristics as opposed to passive characteristics cleft-type speech characteristics that are caused by structural defect or dysfunction (Harding & Grunwell, 1998). Though most of the articulatory characteristics of cleft speech are generic across the board, there are language specific features as well. Hence, what has to be considered an inappropriate substitution in one language may be an acceptable segment in another language.

While some articulation defects appear in an attempt to facilitate phonological development, some articulatory problems have phonological consequences.


In the past, due mainly to the longstanding tradition of a purely anatomic-structural etiology to speech production errors in children with cleft palate (Morris & Ozann, 2003), cleft palate speech has been deemed to be an articulatory disorder. Accordingly, it is normally described by a list of mostly articulatory properties such as atypical consonant productions, abnormal nasal resonance, abnormal nasal airflow, altered laryngeal voice quality, and nasal or facial grimaces (Sell et al., 1999). Nevertheless, the speech problems arising from clefting may have an effect on any or all of speech production subsystems (Howard, 2004); and several studies (Chapman & Hardin, 1992; Chapman, 1993; Grundy & Harding, 1995; Harding and Grunwell, 1995) have shown that the cleft speech defects are of a mixture of articulatory and phonological nature. Further, Stengelhofen (1989) stresses that the subsystems of speech production and actualization are interrelated and therefore should not be treated separately. In addition, many of the features of cleft speech could be regarded as phonological processes since they, in most cases, affect more than one consonant in any given manner or place class (Morris & Ozann, 2003).

Phonological errors identified in cleft speech include, stopping, backing, deletions of final consonants, syllable reduction (Powers et al., 1990; Chapman, 1993), initial consonant deletion, nasalization, velar assimilation, glottal insertion, nasal assimilation, and nasal preference (Chapman & Hardin, 1992; Harding & Grunwell, 1995).

Speech development studies in English

As no detailed documentation of typical speech development in Amharic exists, it is of help to be developed the research from a well-understood theoretical basis.


Earlier efforts to evaluate speech outcomes were generally problematic, partly because they were not done by speech pathologists; and partly because the types and severity of cleft are varied, the features characterizing speech defects in this population are also diverse, making generalisation difficult (Nagarajan, et al., 2009). Indeed, it is well recognized that measuring speech as an outcome of cleft lip and palate is elusive and tricky. Perceptual judgment has been used in several studies to evaluate speech production in cleft population (Howard, 2004), which involves either phonetic transcription or some kind of ratings scale. Such impressionistic assessments would apparently be complex and have problems of consistency and therefore of reliability, indicating a need for a standard approach to perceptual speech analysis (McComb, 19989). Despite this challenge, perceptual speech evaluation still remains to be of the most valuable approach (Sell and Grunwell, 1993 as cited in Howard, 2004; Sell, 2004). It appears that no instrument would replace perceptual judgements; and as Ladefoged (2003:27) observes 'there is no doubt that the ultimate authority in all phonetic questions is the human ear'; but as Howard & Heselwood (2002) and Ladefoged (2003) recognise it, use of instruments in speech analysis is also of importance.


For resonance assessment Training/educational materials can be used together with perceptual judgment substantiated by instrumental measures.

Assessing Articulation

For articulation assessments, tests such as standard or specialized tests can be used. Specialized tests include Iowa Pressure Articulation Test (part of Templin-Darley Tests of Articulation, 1969), Bzoch Error Patterns Diagnostic Articulation Test (1979), Loaded with high-pressure consonants (plosives, fricatives, affricates). The last one is vulnerable in cleft population. Further, good quality audio (visual) recording is also useful permits research, clinical audit, calculation of reliability, EBP.

Evaluate across contexts

Grunwell et al. (1993) stated that a spontaneous or conversational speech sample is important. Kuehn and Moller (2000) detailed that the conversational speech sample may provide important information about consistency or deterioration of articulation proficiency and changes in resonance characteristics.

Nevertheless, sentence sampling is not only an expedient technique in this population but also allows for control of the phonetic content of the elicited speech sample (Sell, 2004).

o isolated words, sentences, conversational speech, isolated phonemes and CV syllables

o Detailed transcription using transcription systems of Shriberg & Kent, 1995; IPA; extIPA (1994; 2002) along with notes of visual information. Then analysis of error of phonological process, place, manner, voicing and Identify error patterns.


Cleft lip and palate may also result in voice defects, which are characterized by hoarseness, breathiness, and deceased loudness during speech, which is usually due to increased muscular and respiratory effort, and hyper-adduction of vocal folds while trying to close the velopharyngeal valve (Kumar, 2008, as cited in Nagarajan & Savith, 2009).


Some (e.g., Harris and Cottam 1985; Bronsted et al 1994) considered characteristics of cleft palate speech patterns to be common across languages. However, due mainly to increase in revolutionary findings from cross-linguistic studies, it has become unlikely to take for granted all the features of cleft speech that were established on the basis of studies on a handful of languages. The purpose of this study is thus to describe the speech outcomes of identified groups of Amharic-speaking individuals with unoperated cleft palate in terms of phonetic and phonological characteristics. More specifically, the study aims to

provide detailed phonetic and phonological descriptions of the different types of mispronunciations and thereby to identify common characteristics of the error identified. This involve description of the magnitude of articulation defects and their phonetic variety in different contexts with reference to the normal limit and analyse the causes and contributing factors of the defects.

assess resonance disorder, which would involve analysis of:

hyprenasality, hyponasality, nasal emission, nasal turbulence, phonetic and phoneme-specific nasal emission.

Vowels, CV syllables, isolated words, sentences, connected speech


In order to provide a detailed phonetic and phonological description of the subjects' speech, different assessment procedures such as recording the frequency of correct pronunciations of the common consonants, ????? will be used.

Regarding method of data collection, type and documentation of the data?????

Given the resources available, the research will????

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