Articulation and Nasality Changes Resulting from Sustained Palatal

Fistula Obturation
JUDITH PINBOROUGH-ZIMMERMAN, PH.D.
CLAUDIA CANADY, PH.D.
DUANE K. YAMASHIRO, D.D.S., M.S.
LOUIS MORALES JR., M.D.
Objective: The purpose of the study was to determine differences in articulation and nasality with obturation over time in children with a palatal fistula.
Design: Articulation and nasality were measured with the fistula open, immediately after obturation, and 4 to 7 weeks postobturation.
Setting, Patients, Participants: Subjects were 15 patients with a palatal fistula
secondary to a repaired cleft palate who were seen through the Orofacial Program, Utah Department of Health, ranging in age from 4 years 6 months to 13
years 1 month.
Interventions: Acrylic palatal obturators were designed to provide coverage
specific to the unique shape and location of each childs fistula. Obturators
were cemented to molar teeth using wire clasps for control of usage.
Main Outcome Measures: Measurements consisted of listener judgments of
hypernasality, hyponasality, and nasal emissions; instrumental ratings of nasalance using the Nasometer 6200-2; and performance on a standardized articulation test.
Results: Significant improvement occurred only on nasal emission measures
from the preobturation condition to immediate postobturation. However, significant improvement was found in articulation, listener judgments of hypernasality, nasal emissions, and Nasometric Nasal Sentence mean scores from
the preobturation condition to 4 to 7 weeks postobturation and from the immediate postobturation condition to 4 to 7 weeks postobturation. No significant
differences were found between conditions for listener judgments of hyponasality and Nasometric Zoo and Rainbow Passage scores. Obturation of the
palatal fistula over a 4- to 7-week period resulted in no adverse effect on articulation ability, perceptual ratings of nasality, or instrumental ratings of nasalance.
Conclusions: Clinical management of patients with a palatal fistula can be
enhanced with treatment using obturation over time. For subjects who continue to exhibit hypernasality immediately postobturation, sustained obturation
is advocated prior to consideration of surgical intervention for treatment of a
palatal fistula and/or velopharyngeal dysfunction.
KEY WORDS: articulation, cleft palate, nasality, nasalance, Nasometry, obturator, palatal appliance, palatal fistula

Speech-language clinicians are often faced with the difficult

problem of determining whether or not articulation problems
and nasality are the result of a palatal fistula, velopharyngeal
dysfunction, or a combination of both. The presence of a palatal fistula can affect the development and continued use of
proper articulation. Misarticulations may result from several
factors, including incorrect tongue placement or weak pressure
consonants. Abnormal nasal resonance and nasal escape of air
are sometimes associated with velopharyngeal dysfunction or
nasal sound transmission through the fistula.
Traditionally, recommendations for surgical management of
the fistula, velopharyngeal dysfunction, and timing of clinical
intervention for speech production problems have included re-

Dr. Pinborough-Zimmerman is Program Manager of the Child Development

Clinic, Utah Department of Health and Adjunct Faculty in the Department of
Communication Disorders, University of Utah. Dr. Canady is Assistant Professor, Department of Communication Disorders, University of Hawaii. Dr. Yamashiro is Director of the Dental Program, Primary Childrens Medical Center,
Salt Lake City, Utah. Dr. Morales is a Professor of Plastic Surgery at the
University of Utah and, with Dr. Yamashiro, affiliated with Pediatric Craniofacial Associates, Salt Lake City, Utah.
Submitted March 1996; Accepted August 1997.
This article was presented at the American Speech-Language Hearing Association Annual Convention, New Orleans, Louisiana, November 1994.
Reprint requests: Dr. Judith Pinborough-Zimmerman, Child Development
Clinic, Utah Department of Health, P.O. Box 144640, Salt Lake City, Utah
84114-4640.
81

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Cleft PalateCraniofacial Journal, January 1998, Vol. 35 No. 1

sults obtained from temporary obturation of a fistula, which

has been used to determine the interaction of a palatal fistula
with velopharyngeal function (Shelton and Blank, 1984; Isberg
and Henningsson, 1987; DAntonio et al., 1992, 1993).
DAntonio et al. (1993) concluded that temporary occlusion
of a palatal fistula may improve velopharyngeal closure. They
suggested that indications for clinical management be based
on an objective evaluation of each patient with the fistula both
patent and occluded. If velopharyngeal function is improved
by temporary obturation, then it may be enhanced further by
sustained obturation.
Previous methods of temporary obturation have included the
application of materials such as chewing gum or dental wax
(Bless et al., 1980; Shelton and Blank, 1984). These types of
materials have not always allowed patients to maintain consistent closure of the fistula for extended periods of testing.
Using obturators that provide coverage for the specific location
and unique shape of the fistula allows for consistency of coverage over time while maximizing the amount of oral mucosa
exposed for tactile feedback. To date, there has been no information available regarding the effects of long-term obturation
on speech and nasality.
The purpose of this study was to determine whether articulation and nasality measures are affected by obturation over
a period of time in children with a palatal fistula. If sustained
obturation results in a significant improvement in speech articulation and/or nasality, then more reliable management decisions can be made regarding the need for surgical and speech
interventions.
METHOD
Subjects
The subjects for the study were 15 children ranging in age
from 4 years 6 months to 13 years 1 month, each with a palatal
fistula secondary to a repaired cleft palate. The mean age of
the subject group was 8 years 9 months. All subjects but one
were male. Type of cleft, age, gender, and previous secondary
palatal procedures are presented in Table 1.
All subjects had undergone primary surgical repair of the
cleft palate. For some, the fistula was a sequela of this surgical
repair. For others, the fistula developed as a result of lateral
maxillary arch expansion. Individuals were not included as
subjects if their palatal fistula was the result of carcinoma or
if the location of the fistula prevented adequate obturation.
All subjects were found to have hearing thresholds less than
25 dB for the frequencies 500 to 2000 Hz. A review of health
department records indicated that all subjects had normal intellectual capacity. None of the subjects had a documented
conduct disorder. The primary language for all 15 subjects was
English.
Assessments of children with colds, allergies, or sinus infections were postponed until no symptoms were reported.
None of the subjects received articulation therapy or nasality
treatment while participating in the study. None of the partic-

TABLE 1 Subject Characteristics

Subject Diagnosis*
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15

UCLP
BCLP
BCLP
BCLP
UCLP
UCLP
CP
BCLP
BCLP
BCLP
UCLP
BCLP
UCLP
UCLP
UCLP

9
11
8
13
10
5
11
4
7
9
8
12
9
5
6

years
years
years
years
years
years
years
years
years
years
years
years
years
years
years

Age

Sex

6 months

M
M
M
M
M
M
M
M
M
M
M
M
M
M
F

10 months
1 month
1 month
2 months
1 month
6 months
1 month
4 months
7 months
7 months
1 month
5 months
1 month

Secondary Palatal
Management
Flap/takedown
Flap/revision 3 2

Flap

Flap

Flap/revision 3 1
Orticochea
Flap
Flap
Flap

* CP 5 cleft palate; BCLP 5 bilateral cleft lip and palate; UCLP 5 unilateral cleft lip and
palate.

ipating subjects had worn an obturator within the previous 3

years.
Speech Articulation Assessment
Articulation was assessed under three research conditions:
preobturation, immediately postobturation, and 4 to 7 weeks
postobturation. The GoldmanFristoe test of articulation
(Goldman and Fristoe, 1986) was administered to all subjects
in all research conditions. Audiotapes were made of the
Sounds-in-Words subtest using an Optimus high-speed dubbing stereo cassette deck and a Realistic 33-2012 One Point
stereo microphone as recording equipment.
The articulation test was administered in accordance with
accepted procedures by a licensed certified speech pathologist
with 15 years experience on a craniofacial team (J.P.-Z.). The
number of errors occurring for each sound and subject percentile ranks were computed for each condition of obturation
for all subjects.
A second licensed certified speech pathologist scored the
randomized audiotapes of the GoldmanFristoe test of articulation Sounds-in-Words subtest. The second rater had no
knowledge of the condition of obturation. A comparison was
made between the articulation measures found by the two independent raters. Rating comparisons were obtained on all 45
articulation tests. Using the Spearman two-tailed correlation
coefficient test, the correlation coefficient between the two
judges ratings of articulation was found to be 1.99 for each
condition of obturation.
Nasality Assessment
Listener judgments of nasality during conversational speech
were determined by the investigator (J.P.-Z.) for all subjects
for each condition of obturation. Hypernasality and hyponasality were each rated separately on a 6-point scale, with a 0
rating equivalent to normal resonance; 1, mild nasality; 2, mild

Pinborough-Zimmerman et al., ARTICULATION AND NASALITY CHANGES

to moderate nasality; 3, moderate nasality; 4, moderate to severe nasality; and 5, severe nasality.
Hypernasality, hyponasality, and nasal emissions were also
rated by the investigator from the randomized audiotapes containing the articulation test for all subjects for each condition
of obturation. Nasal emissions were rated on a 3-point scale,
with a 0 rating equivalent to no nasal emissions; 1, inconsistent
nasal emissions; and 2, consistent nasal emissions.
A comparison was made between the primary investigators
ratings of hypernasality and hyponasality for all subjects for
each condition of obturation. Using the Pearson two-tailed correlation coefficient test, the intrajudge correlation ratings for
hypernasality were 1.91 (p 5 .01) for preobturation condition,
1.79 (p 5 .01) for the immediate postobturation condition,
and 1.99 (p 5 .01) for the 4- to 7-week postobturation condition. Intrajudge correlation ratings for hyponasality were
1.79 (p 5 .01) for the preobturation condition, 1.66 (p 5
.01) for the immediate postobturation condition, and 1.88 (p
5 .01) for the 4- to 7-week postobturation condition.
Interjudge reliability measures of hypernasality, hyponasality, and nasal emissions were calculated between the investigator and a third licensed certified speech pathologist for 42%
of the study sample. Using the Pearson two-tailed correlation
coefficient test, the correlation coefficient found between the
two raters was 1.76 (p 5 .01) for nasal emissions and 1.77
(p 5 .01) for hypernasality. Hyponasality ratings were not significantly correlated; however, 16 of the 19 ratings were identical.
Subject nasality was assessed instrumentally under the three
obturation conditions using the Nasometer 6200-2. Nasalance
scores were computed for all subjects from three standardized
passages: Zoo, Rainbow, and Nasal Sentences (Kay Elemetrics
Corp, 1987). Some of the children were nonreaders; therefore,
all subjects were asked to repeat short phrases after the examiner.
Using the Spearman rank correlation coefficient test, the
correlation coefficient between listener judgments of hypernasality and Zoo passage scores was found to be 1.84 (p 5
.01) for the preobturation condition, 1.92 (p 5 .01) for the
immediate postobturation condition, and 1.82 (p 5 .01) for
the 4- to 7-week postobturation condition. The correlation coefficient between listener judgments of hyponasality and Nasal
Sentences scores was found to be 2.66 (p 5 .01) for the
preobturation condition, 2.77 (p 5 .01) for the immediate
postobturation condition, and 2.55 (p 5 .05) for the 4- to 7week postobturation condition.
Obturation
Immediately after the preobturation speech and nasality assessments, dental impressions were taken by an orthodontist.
The casts obtained from the impressions were used to construct
an obturator for each subject. Obturators were fashioned from
acrylic and designed to provide coverage that was defect-specific. While providing specific coverage for the fistulas location and shape, all obturators included an additional 2 to 3 mm

83

of material around the perimeter to prevent air leakage. The

edges of the obturator were smoothed, and the acrylic was
buffed to produce minimal mechanical irritation to the surrounding oral mucosa. During obturator fabrication, wire
bands were placed into position. These wire bands were then
used to cement the appliance to the molar teeth (Fig. 1). The
orthodontist attempted to create a tight seal over the fistula
with the obturator flush against the oral mucosa. Adjustments
to the fitting were made until the patient indicated that no air
could be blown through the roof of the mouth.
Size and Location Measurements
Fistula size for each subject was determined from the maxillary cast by the speech pathologist in conjunction with the
orthodontist. Fistula length and maximal width were measured
in millimeters, and the total area was calculated for each subject. Fistula size ranged from 3.0 to 84.0 mm2. Clark et al.
(1992) demonstrated that the functional aperture of an oronasal
fistula is not completely reliable when judged from an intraoral
view. For the purposes of this study, size measurements were
primarily important for obturator fabrication, and thus measurements of size discrepancy between oral and nasal surfaces
were not compared.
The location of the fistula was classified into one of the
following categories: postalveolar to incisive foramen, hard
palate, junction of the hard and soft palate, soft palate, and
postalveolar/hard palate. Table 2 shows the locations and measurements of the fistulas for all subjects. None of the subjects
presented with a fistula in the soft palate or at the junction of
the hard and soft palate.
Data Analyses
Articulation percentile ranks for all subjects were tabulated
for each condition of obturation. The Wilcoxon matched-pairs
signed-ranks test was used to determine significant differences
between the three conditions using subject articulation raw
scores and error in individual sound productions. Observations
of articulation patterns were addressed descriptively.
Listener judgments of hypernasality, hyponasality, and nasal
emissions for individual subjects for the three conditions of
obturation were analyzed. The Wilcoxon matched-pairs
signed-ranks test was used to determine significant differences
between conditions in perceived nasality and nasal emissions.
The Wilcoxon matched-pairs signed-ranks test was used to
determine whether significant differences existed between conditions of obturation for each of the Nasometric test passages.
For the three conditions of obturation, the Nasometric group
means were calculated on the three test passages, Zoo, Rainbow, and Nasal Sentences.
RESULTS
Articulation
Comparisons of total articulation raw scores for all subjects
over conditions of obturation are shown in Table 3. Overall,

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Cleft PalateCraniofacial Journal, January 1998, Vol. 35 No. 1

FIGURE 1 Obturator attachment to molars in subject 3.

there was no significant change in articulation from the preobturation condition to the immediate postobturation condition (p
5 .31). However, significant improvement (p , .001) in articulation was found with sustained obturation (changes in articulation raw scores between preobturation and 4 to 7 weeks

TABLE 2 Distribution of Fistula Lengths, Widths, Sizes, and Locations

(n 5 15)
Subject
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15

Fistula Length Fistula Width

(mm)
(mm)
15.0
6.0
12.0
5.0
12.0
9.5
15.0
20.0
4.0
14.0
16.0
15.0
15.0
21.0
3.0

1.0
5.5
1.0
5.0
4.0
1.0
1.0
3.0
1.5
6.0
1.0
2.0
1.5
3.0
1.0

Fistula Size
(mm2)
15.0
33.0
12.0
25.0
48.0
9.5
15.0
60.0
6.0
84.0
16.0
30.0
22.5
63.0
3.0

Location*
PAIF
PAHP
HP
PAHP
PAHP
PAIF
HP
PAHP
PAIF
PAIF
PAHP
PAHP
PAIF
PAHP
HP

* PAIF 5 postalveolar to incisive foramen; HP 5 hard palate; PAHP 5 postalveolar and hard
palate.

postobturation, and between immediate postobturation and 4

to 7 weeks postobturation).
Articulation errors prior to obturation consisted primarily of
posterior tongue placement errors on sibilant sounds causing
oral distortions. Significant improvement in sound production
after 4 to 7 weeks of obturation was considered to be a result
of the subjects use of a more anterior tongue placement.
The five most frequently misarticulated sounds for all subjects and conditions were /t1/, /z/, /d^ /, /s/, and /1/. Of the 35
sounds tested on the GoldmanFristoe test of articulation, only
3 sounds, /1/, /d^ /, and /t1/, showed significant differences in
the number of errors between conditions (Table 4). It should
be noted that these are three of the five most frequently
misarticulated sounds.
TABLE 3 Comparisons of Subject Changes in Articulation Raw Scores
Over condition of Obturation (n 5 15)

Measurement
Articulation

Number of Subjects

Comparison of
Conditions*

2 Rank

1 Rank

Tie

1 with 2
1 with 3
2 with 3

5
13
13

4
1
2

6
1
0

* 1 5 preobturation; 2 5 immediately postobturation; 3 5 4 to 7 weeks postobturation.

p , .001 (two-tailed Wilcoxon matched-pairs signed-ranks test).

Pinborough-Zimmerman et al., ARTICULATION AND NASALITY CHANGES

TABLE 4 Number of Subjects with Error Sound Change Over

Condition of Obturation (n 5 15)

Sound
Shovel

Jumping

Church

1
1
2
1
1
2
1
1
2

with
with
with
with
with
with
with
with
with

TABLE 6 Subject Comparisons of Changes in Nasometric Measures

Over Condition of Obturation (n 5 15)

Number of Subjects

Comparison of
Conditions*

2 Rank

1 Rank

Tie

Nasometric Passage

2
4
6
4
8
6
5
7
5

2
1
0
1
0
0
0
1
2

11
10
9
10
7
9
10
7
8

Zoo

2
3
3
2
3
3
2
3
3

* 1 5 preobturation; 2 5 immediately postobturation; 3 5 4 to 7 weeks postobturation.

p , .05 (two-tailed Wilcoxon matched-pairs signed-ranks test).
p , .01 (two-tailed Wilcoxon matched-pairs signed-ranks test).

In all cases where significant differences were found in the

number of articulation errors over condition of obturation,
there was a reduction in articulation errors with obturation. No
significant increase was found in articulation errors as a condition of obturation for any of the 35 sounds tested.

Rainbow

Nasal sentences

TABLE 5 Subject Comparisons of Changes in Listener Ratings of

Hypernasality, Hyponasality, and Nasal Emission Measures Over
Condition of Obturation (n 5 15)

Hyposnasality

Nasal emissions

1
1
2
1
1
2
1
1
2

with
with
with
with
with
with
with
with
with

2 Rank

1 Rank

Tie

8
9
7
7
7
7
7
4
4

7
6
8
8
8
8
8
10
11

0
0
0
0
0
0
0
1
0

2
3
3
2
3
3
2
3
3

between preobturation and 4 to 7 weeks postobturation (p ,

.05), and between immediate postobturation and 4 to 7 weeks
postobturation (p , .05). Normative population and group
mean scores for each condition of obturation are presented in
Table 7.
DISCUSSION

The changes in nasality and nasal emissions associated with

condition of obturation are presented in Table 5. A significant
difference was found only in measures of listener judgment of
nasal emissions when comparing preobturation with immediate
postobturation (p 5 .01). Significant differences, however,
were found in measures of listener judgment of hypernasality
(p , .01) and nasal emissions (p , .05) between preobturation
and 4 to 7 weeks postobturation. Significant differences occurred on measures of listener judgments of hypernasality (p
, .05) and nasal emissions (p , .01) between immediate postobturation and 4 to 7 weeks postobturation (p , .05).
The changes in Nasometric measures over condition of obturation are presented in Table 6. No significant differences
were found in any of the Nasometric measures when comparing preobturation with immediate postobturation. Significant
differences were found in nasalance scores for Nasal Sentences

Hypernasality

Number of Cases

Comparison of
Conditions*

* 1 5 preobturation; 2 5 immediately postobturation; 3 5 4 to 7 weeks postobturation.

p , .05 (two-tailed Wilcoxon matched-pairs signed-ranks test).

Nasality Results

Listener Ratings

85

Comparison of
Conditions*
1
1
2
1
1
2
1
1
2

with
with
with
with
with
with
with
with
with

2
3
3
2
3
3
2
3
3

Number of Cases

2 Rank

1 Rank

Tie

5
10
6
1
2
2
6
4
8

3
2
1
2
0
0
0
0
0

7
3
8
12
13
13
9
11
7

* 1 5 preobturation; 2 5 immediately postobturation; 3 5 4 to 7 weeks postobturation.

p , .01 (two-tailed Wilcoxon matched-pairs signed-ranks test).
p , .05 (two-tailed Wilcoxon matched-pairs signed-ranks test).

The findings of this study showed significant improvement

in articulation scores with sustained fistula obturation, although
significant articulation change between preobturation and immediate postobturation was not observed. Other studies have
suggested that immediate meaningful improvement in intelligibility and speech results from obturation (Henningsson and
Isberg, 1987) or surgical closure of a fistula (Kanabara 1975).
The sample sizes (varying between 10 and 17 subjects) were
similar among these studies. However, measures of speech production, analysis of data, and type of obturation differed. Obturators were attached for the duration of the current study,
while former studies relied on the temporary application of
chewing gum (Henningsson and Isberg, 1987) or surgical closure (Kanabara, 1975). A unique focus of the present investigation was the use of an orthodontically fixed appliance designed to provide defect-specific coverage of the fistula. Obturators that are not defect-specific may cover a greater area
than the fistula itself, thus inhibiting tactile feedback used in
articulation. If not fixed in place, they also may be less stable.
Improvement of articulation has been considered one reason
for surgical treatment of fistulas. The improvement in articulation that occurred after sustained obturation indicates that
obturation of a palatal fistula may be warranted for those chilTABLE 7 Normative Population and Group Mean Scores by Condition
of Obturation (n 5 15)

Nasometric Passage
Zoo
Rainbow
Nasal sentences

Normative
Population
Mean

15.53
35.69
61.06

31.06
39.41
52.30

28.97
39.54
52.49

29.06
41.71
57.45

Subject Means by Condition*

* 1 5 preobturation; 2 5 immediately postobturation; 3 5 4 to 7 weeks postobturation.

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Cleft PalateCraniofacial Journal, January 1998, Vol. 35 No. 1

dren who exhibit articulatory error patterns for which the place
of articulation and the location of the fistula are similar. In
most cases, this obturation would be temporary until definitive
surgical closure is accomplished.
In the present study, there was a significant group difference
in listener judgment measures of nasal emissions between the
preobturation condition and the immediate postobturation condition. This finding is consistent with the study by DAntonio
et al. (1993) which showed more reduction in frequency of
nasal emission and perceived oral pressure than in hypernasalance.
An unexpected finding of the study was a significant (p ,
.05) increase in Nasal Sentences mean scores over time. Subject scores gradually approached the normative mean on these
sentences, in which nasal consonant phonemes are three times
more prevalent than in standard American English sentences.
Reduced nasality is often related to obstruction of the nasal
cavity, leading to an expectation that the presence of an obturator might decrease nasalance scores on these sentences.
Perhaps normalization of Nasal Sentences mean scores is
merely a reflection of the improved function of the speech
mechanism with sustained obturation. It may be that with sustained obturation of the fistula, velopharyngeal movement continues to improve, and articulation improves, as does the ability of the velopharyngeal port to obtain open and closed states
as is required for the Nasal Sentences.
Lack of significant improvement in group measures of hypernasality and Nasometric Zoo and Rainbow nasalance scores
between preobturation and immediate postobturation was an
unanticipated finding of this study. Other studies suggest that
improved resonance, aerodynamic characteristics of speech,
and velopharyngeal functioning result from temporary occlusion of hard palate fistulae (Shelton and Blank, 1984; Isberg
and Henningsson, 1987; DAntonio et al., 1993). A possible
explanation for the difference in the current findings from
those of previous reports is the high number of children in this
population (73%) who had previously undergone secondary
palatal management for velopharyngeal insufficiency. In the
population described by DAntonio et al.(1993), none of the
children had secondary palatal management prior to the study.
Another possible explanation for this difference is the number of subjects in this study who had continued abnormal resonance despite 4 to 7 weeks of obturation. Thirty-three percent
of the subjects continued to have abnormal ratings for hypernasality with long-term obturation. When subjects who continued to have abnormal ratings of nasality either in the immediate postobturation condition or the 4- to 7-week postobturation condition were compared with those subjects who had
prior secondary palatal management procedures, no apparent
pattern emerged.
Despite the fact that group differences in hypernasality, Zoo
passage, and Rainbow passage scores did not reach significance levels from the preobturation condition to the immediate
postobturation condition, there was marked individual subject
variability between the conditions that was consistent with reports on temporary obturation. For example, normal listener

ratings of resonance were obtained by 2 subjects in the preobturation condition. This increased to 5 subjects in the immediate postobturation condition and to 10 subjects in the 4- to
7-week postobturation condition. These results suggest that immediate obturation of the fistula in three of the subjects resulted in elimination of hypernasality symptoms. It is unclear
whether this immediate change was the result of reduced airflow through the fistula alone, or of reduced airflow through
the fistula as well as improved velopharyngeal closure. Isberg
and Henningsson (1987) and DAntonio et al. (1993) have
both reported changes in velopharyngeal function associated
with obturation of a palatal fistula.
The findings in this study lend support to the recommendation that treatment decisions regarding the effects of a palatal
fistula on speech should be based on the objective evaluation
of each patient with the fistula open and occluded. Futhermore,
for subjects who continue to exhibit hypernasality immediately
postobturation and/or have articulation errors related to the fistula, sustained obturation is advocated prior to decisions for
surgical management of a fistula and/or velopharyngeal function.
Hypernasality resolved in five subjects only after 4 to 7
weeks of obturation. Consequently, management decisions
based on assessments of hypernasality immediately after obturation without continued obturation and further assessments
may result in unnecessary surgical and speech interventions
for these subjects.
For the remaining five subjects, whose hypernasality did not
resolve with sustained obturation, velopharyngeal function
continued to be a management concern. Further investigation
is needed to determine if obturation continued past a 4- to 7week period would result in continued improvement in speech
and nasality for individual subjects.
CONCLUSIONS
Location-specific obturation over a 4- to 7-week period resulted in significant improvement in the articulation scores of
children with palatal fistulas. Nasal emissions significantly decreased immediately postobturation and 4 to 7 weeks postobturation. Additionally, hypernasality based on listener judgments was found to significantly decrease over time in some
subjects with obturation of the palatal fistula. Nasometric analyses on the Zoo passage, the Rainbow passage, and Nasal Sentences revealed significant changes over time only for Nasal
Sentences. Measurements of articulation, hypernasality, and
hyponasality conducted immediately postobturation revealed
no significant changes in group scores from the preobturation
measurements. There was, however, marked individual variability in articulation and nasality measures immediately following obturation. These findings indicate that clinical management decisions for patient care should include the option
of sustained obturation. For individuals with persistent hypernasality immediately postobturation, sustained obturation is
advocated prior to the formulation of surgical and speech intervention plans.

Pinborough-Zimmerman et al., ARTICULATION AND NASALITY CHANGES

Acknowledgments. The authors thank Marilyn Howe, M.S., for her assistance
in data analysis, and Primary Childrens Medical Center for the use of the
Nasometer.

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