Cleft Lip and Palate – Flashcards
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Identify the major anatomic structures involved in velopharyngeal movement
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Hard palate, premaxilla, soft palate, uvula, legator tensor palati, posterior pharyngeal wall, lateral pharyngeal wall
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Hard Palate
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anterior two thirds of the palate, comprised of the premaxilla, the paired palatine processes of the maxilla, and the paired palatine bones; covered with a layered combination of mucous membrane (mucoperiosteum) and a fibrous membrane that covers the bone (periosteum)
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Palatal vault
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Roof of the mouth and floor of the nasal cavity
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Alveolar ridge
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Outer rim of the hard palate; Forms base and bony support for teeth
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Mucoperiosteum
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Tissue covering the hard palate; Mucous membrane (mucosa) - stratified squamous epithelium
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Periosteum
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thick, fibrous membrane that covers bone
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Rugae
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Folds, ridges or creases in a structure; Transverse ridges in the mucosa of the hard palate
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Incisive Papilla
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Slight elevation of mucosa at anterior end of raphe of the palate
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Median (palatine) raphe
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Line of union between two bilaterally symmetric structures; Midline of the mucosa covering the hard palate; Runs from incisive papilla to border of hard palate
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Premaxilla
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Triangular-shaped bone that is bordered by incisive suture lines; Dental arch contains central & lateral maxillary incisors
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Incisive Foramen
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Hole in the palate to allow blood vessels& nerves to pass through; Located at tip of premaxilla
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Incisive suture lines
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Embryological suture lines that go between the lateral incisors and canines and meet at the incisive foramen
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Palatine processes
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Paired projections of the maxillary bone; Posterior to incisive suture lines; Form anterior 3/4 of maxilla
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Soft palate (velum)
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posterior one third of the palate, comprised of mainly muscle, adipose tissue, connective tissue, granular tissue, and overlying mucous membrane - anatomical name is velum; space surrounded by the velum and the lateral pharyngeal walls and the posterior pharyngeal wall is the velopharyngeal port
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Describe the function of the velopharynx in normal speech production (and to a limited extent, swallowing)
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a. The velopharynx is a complete, three-dimensional valve, which serves to uncouple the oropharynx and nasopharynx during speech and swallowing. The levator veli palatini is the primary muscle responsible for velar elevation, hence for velopharyngeal closure, during speech and swallowing. Fine motor control of velar position may be governed by the palatoglossus and palatopharyngeus. b. The velum lifts posteriorly and superiorly during velopharyngeal closure. Velopharyngeal contact is made between the velum and the posterior pharyngeal wall. The contribution of lateral pharyngeal wall movement to velopharyngeal closure varies amongst individual with or without cleft palate and varies with the phonemic task.
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Basic patterns of velopharyngeal closure:
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i. Coronal - closure is effected primarily by velar elevation (observed most commonly in both normal individuals and patients with VPD) ii. Circular (with or without Passavant's ridge) - medial movement of the lateral pharyngeal walls contributes to velopharyngeal closure in near-equal proportion to the velum 1. Passavant's ridge - transverse ridge of tissue on the posterior pharyngeal wall iii. Sagittal - closure is effected primarily by medial movement of the lateral pharyngeal walls
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Differentiate voice from speech resonance
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a. Voice is the vibration of the vocal folds (source), whereas resonance is everything that happens above the vocal folds to filter the voice (filter) (the shape of the oral cavity, the location of the articulators, the valve), it is all the stuff that alters the sound. b. Voice and resonance are NOT the same thing!
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Explain in lay terms what an oral cleft is.
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a. An oral cleft is an opening in the lip, alveolar ridge, hard palate, and or soft palate. b. It is the failure of the tissues to fuse together during fetal development.
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Cleft lip
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i. Can vary from a small defect to a complete cleft extending to and through the floor of the nostril ii. A cleft lip is when the lip has failed to fuse together iii. A cleft lip is a separation of the two sides of the lip. The separation often includes the bones of the upper jaw and/or upper gum.
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Cleft Palate
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i. A cleft palate is when the palate has failed to fuse together ii. A cleft palate is an opening in the roof of the mouth in which the two sides of the palate did not fuse, or join together, as the unborn baby was developing. Cleft lip and cleft palate can occur on one side (unilateral cleft lip and/or palate), or on both sides (bilateral cleft lip and/or palate). Because the lip and the palate develop separately, it is possible for the child to have a cleft lip, a cleft palate, or both cleft lip and cleft palate.
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Unilateral cleft lip and palate
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did not fuse on one side
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Bilateral cleft lip
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No fusion on either side
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Unrepaired cleft palate
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intact, alevolar arch
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Microform (submucous cleft palate)
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bifid uvula, blue whitish in the midline (blue raphe) mucous layer is intact but a cleft is underneath, thin layer of skin with nothing underneath it, v-shaped notch in roof of the mouth instead of a u-shaped, uvula might not be completely bifid, might just be notched - may not always have an impact on speech, often undiagnosed
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Fistula
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an abnormal opening, usually referring to a hole in a palate after repair
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Malocclusion
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a deviation from normal occlusion, that is, incorrect positioning of the upper teeth in relation to the lower teeth
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Palatoplasty
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aka palatorraphy, surgery on the palate
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Hypernasality
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speech that sounds overly "nasal" as if the person is "talking through his or her nose;" too much energy through your nose, most often heard on the vowel
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Hyponasality
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denasality, a lack of normal nasal resonance during speech; not enough energy through your nose
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Mixed resonance
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both hypernasality and hyponasality
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Cul-de-sac resonance
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occlusion in the nasal cavity, sound gets in the nasal cavity and can't get out and will move around in there, variation of hyponasality
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nasal air emission
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aka nasal air escape; an abnormal flow of air through the nose during speech. Usually indicative of an incomplete seal between oral and nasal cavities.
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Identify sources of velopharyngeal dysfunction aside from oral cleft conditions
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a. Structural i. Cleft palate ii. Tonsils to big iii. Palate is too short iv. Short velum v. Hypotonia vi. Adenoid removal vii. Big palate viii. Unusual shaped palatal arch b. Neurological i. Stroke ii. Paralysis iii. Apraxia c. Mislearning i. Phoneme specific VPI (velopharyngeal inadequacy) d. Categories - functional, organization, neurological
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syndrome
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multiple anomalies (multiple defects) in one or more tissues occurring together in an individual but having a single pathogenesis
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congenital
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a disease, deformity, or deficiency existing at the time of birth
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genetic
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determined by properties of the genes. By definition, genetic conditions are congenital (present at birth), but the opposite is not true because congenital conditions may be genetic, chromosomal, teratogenic, multifactorial, or unknown in etiology
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Dysmorphology
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the study of abnormal form; the study of human malformations
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Variable expressivity
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occurs when a phenotype is expressed to a different degree among individuals with the same genotype
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Karyotype
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the chromosomal characteristics of a cell; the appearance and characteristics of the chromosomes of a cell, especially size, number, and form; a picture, or organized graphic representation of the chromosomes in a single cell
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Genotype
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the genetic makeup of an organism
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Phenotype
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the physical manifestations of a single gene
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Basic patterns of inheritance
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Mendelian patterns - autosomal dominant, autosomal recessive, and non-Mendelian patterns
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Mendelian patterns of inheritance
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single-gene or monogenic conditions are caused by the particular allele at a single locus. There are three subcategories: autosomal dominant inheritance, autosomal recessive, non-mendelian
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Autosomal dominant inheritance
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a condition that is expressed phenotypically when only one allele is mutant or defective is said to be dominant. There is a 50% chance of this dominant gene being transmitted to the next generation. Males and females are equally likely to be affected.
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Autosomal recessive inheritance
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conditions occur only when both alleles on a chromosome pair are abnormal, that it, the child receives a mutant allele from each parent. The affected individual is said to be homozygous for the mutant gene; heterozygous individuals have only a single copy of the abnormal gene and are unaffected. Offspring have a 50% of being a carrier and a 25% chance of being affected, and a 25% chance of being neither affected nor a carrier. (autosomal recessive conditions tend to be more severe than dominant disorders)
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Non-Mendelian inheritance
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certain patterns that are exceptions to Mendelian inheritance. 1. In some genetic conditions the sex of the parent that contributed the mutant allele influences the expression of the gene. This is called genomic imprinting. 2. Uniparental disomy - both chromosomes of the pair are inherited from one parent 3. Isodisomy - two copies of the identical parental chromosome 4. Heterodisomy - both the defective and nondefective chromosome are inherited from one parent (wholly maternal or paternal chromosome pair) 5. A mutation in a mitochondrial gene will be transmitted to offspring
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genetic imprinting
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In some genetic conditions the sex of the parent that contributed the mutant allele influences the expression of the gene
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Uniparental disomy
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both chromosomes of the pair are inherited from one parent
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Isodisomy
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two copies of the identical parental chromosome
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Heterodisomy
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both the defective and non-defective chromosome are inherited from one parent (wholly maternal or paternal chromosome pair)
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Major and minor malformations that may accompany oral clefts
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lip pits, auricular malformations, and the importance of obtaining a good medical history including other birth anomalies such as cardiac conditions
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Van der Woude Syndrome
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i. Lip pits - pits in the lower lip ii. Variety of clefts of the lip and or palate (not always present) iii. Hypodontia - missing teeth because of failure for those teeth to develop (VWS) iv. Abnormalities of the nipples
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Pierre Robin Sequence
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i. Micrognathia (small jaw)/retrognathia (jaw condition in which either or both jaws recede with respect to the frontal plane of the forehead) ii. Glossoptosis - downward placement or retraction of the tongue iii. Cleft palate (not in all cases) iv. Respiratory and feeding problems (most but not all cases)
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Stickler Syndrome
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i. Hereditary eye and long-bone problems ii. Progressive sensorineural hearing loss iii. Micrognathia/retrognathia iv. Glossoptosis v. Cleft palate (not in all cases) vi. Respiratory and feeding problems (most but not all cases)
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Fetal Alcohol Syndrome
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i. Prenatal and postnatal growth deficiency ii. Microcephaly - small head or having a reduced space for the brain in the skull, often associated with learning difficulties iii. Short palpebral fissures - short longitudinal opening between the upper and lower eyelids iv. Epicanthal folds - skin fold of the upper eyelid, covering the inner corner of the eye v. Thin upper lip with a smooth philtrum vi. Flat, broad nasal bridge vii. Small nose viii. Flat midface ix. Abnormally formed ears x. Underdeveloped lower jaw
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Velocardiofacial Syndrome
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i. Cardiac defects (present in about 80% of cases) ii. Prenatal and postnatal growth deficiency (small stature) iii. Variable defects of the velopharyngeal system (not always present) iv. Retruded mandible v. Learning disabilities vi. Poor fine motor coordination vii. Small hands with tapered fingers viii. Unusual facies, with reduced facial expression, thin upper lip, narrow palpebral fissures, large nose with flattened nasal bridge, flat malar region, variable anomalies of the auricles (ears - pinna) ix. Likelihood of psychiatric disorders
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Hemifacial Micromia
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i. Abnormal form and growth of the ramus of the mandible ii. Possible associated malformations of the auricle and middle ear; rare reports of associated involvement of the inner ear iii. Possible asymmetries of other oral structure including the labial commissure, palate, and tongue iv. Possible involvement of the neurocranium, maxilla, orbits, and temporal bone
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Explain the connection between middle ear infection, Eustachian tube dysfunction, and cleft palate.
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The musculature of the velopharyngeal system is tied to that of the eustachian tube. The eustachian tube provides aeration of the middle ear cavity, equalization of pressure between the middle ear cavity and the ambient pressure, and drainage of middle ear fluid and secretions into the nasopharynx. The tensor veli palatini is the main muscle that opens the eustachian tube. Children with clefts are highly susceptible to middle ear disease most likely because the cleft interferes with the ability of the tensor to open the eustachian tube. When the eustachian tube cannot be open efficiently the middle ear cannot be ventilated, the tympanic membrane retracts and an effusion from the middle ear mucosa develops as the negative pressure increases within the middle ear cavity. The negative ear pressure increases also draw bacteria into the middle ear. The bacteria causes a middle ear infection.
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Explain the term "compensatory articulation" and give an example of a compensatory use of a glottal stop and a more typical use of a glottal stop
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a. Compensatory articulation - attempt to articulate pressure consonants at the larynx or pharynx rather than with the oral cavity; atypical pattern of articulation b. Glottal stops are the most common compensatory articulations produced by individuals with cleft palate c. Typically occur as substitutions for oral stop consonants, but also fricatives and affricates d. /feather/ would be /fea?er/, normal /bu?on/ for "button"
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Summarize the findings of prelinguistic productions among infants with oral clefts and the role of early counseling and preventive strategies to foster speech-language development
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a. Infants with oral clefts typically have velopharyngeal inadequacy as well as dental abnormalities, causing issues with resonance and articulation. Hearing problems are also associated with clefts, which contribute to a later onset of first words as well as language delays. Early counseling and repair of the cleft with surgery can reduce these problems. Parents must be educated on how the cleft can affect early communicative efforts, and they should be encouraged to start stimulating language (i.e. vocal play and babbling) even before palatal surgery. It should be a goal to increase the child's consonant inventory and avoid reinforcement of maladaptive sounds. Parents must play an active role in their child's speech-language development
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Explain the advantages (importance) of interdisciplinary team care for individuals with oral cleft conditions.
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i.Quality health and psychosocial care. ii. Teams consist of experts in their field. iii. Professionals consult before making decisions. iv. The greater number of patients seen by a team, the greater likelihood of quality care. The American Cleft Palate-Craniofacial Association (ACPA) and the Cleft Palate Foundation (CPF) maintain committees for certification and team standards (what disciplines should be included, # of cases seen each year, # of surgical procedures). v. Team care is more affordable for the family and third-party payer. vi. Fewer office visits are required. vii. Consultation reduces the need for salvage treatment procedures. viii. Continuity of care for the patient.
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Disadvantages of interdisciplinary team care
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i. Resistance from third-party payers because the importance of team care is not fully understood. ii. Some team members may exert more influence on decision- making based on their status (age, gender, discipline, experience). For a quality team, there must be mutual respect and equality. iii. Problems can arise if individual roles aren't clearly defined.
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Identify the three core team members and at least 3 additional members that are likely to be present on a cleft or craniofacial team.
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a. Three core team members: SLP, Orthodontists, and Plastic Surgeon b. 3 (or more) additional members: audiologist, genetic counselor, psychologists, nurse, social worker
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The 3 cardinal features of submucous cleft are:
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i. a bifid uvula ii. blue raphe of the soft palate (a midline or diastasis of the musculature of the soft palate) ( this is what results in a pale blue color along the midline of the soft palate) iii. v-shaped notch at the back of the hard palate iv. These 3 features may not always appear together
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Describe the clinical features of submucous cleft palate and occult submucous cleft palate
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a. The 3 cardinal features b. The SLP may be the first to recognize that the submucous cleft is present. c. If you come across a child with a cleft palate, you can send them to a cleft palate team or a developmental physician. They can determine if the cleft is related to a syndrome. d. Occult submucous cleft: A defect in the muscular bulk of the soft palate that can be seen only on nasendoscopy (even when none of the 3 cardinal features of submucous cleft are present) i. has unusual resonance, but not visible signs of a submucous cleft, at least not until you look at it through a nasal scope
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Occult submucous cleft
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A defect in the muscular bulk of the soft palate that can be seen only on nasendoscopy (even when none of the 3 cardinal features of submucous cleft are present) i. has unusual resonance, but not visible signs of a submucous cleft, at least not until you look at it through a nasal scope
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Identify multiple causes of velopharyngeal (VP) dysfunction
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a.*See Velopharyngeal Inadequacy (VPI) chart from Week 1 b. a previously undiagnosed occult submucous cleft, with a muscular deficiency on the upper surface of the velum c. Palatopharyngeal disproportion (a mismatch between the length of the velum and the depth of the pharynx) i. Possible contributors to this disproportion: a short soft palate, abnormal pharyngeal depth, incautious adenoidectomy or tonsillectomy that creates an excessively deep pharynx d. Mechanical Obstruction to complete velopharyngeal closure (tonsils, irregularly shaped adenoid pad, irregularities of the faucial pillars) e. Deficient movement of the velum or pharyngeal components of velopharyngeal closure occurring (could be occurring in isolation or as a part of a neuromotor impairment of other parts of the speech mechanism [i.e. apraxia, dysarthria]) f. Mislearning (phoneme specific nasal emission)
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Describe the location of adenoid tissue and its role in VP closure in young children
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Adenoid tissue is located behind the nasal cavity, right above the tonsils (the roof and posterior wall of nasopharynx). It is soft tissue. For young children whose adenoid pads are still intact, the velum has less of a distance to travel during velopharyngeal closure. The adenoids help the velum to close off the velopharyngeal valve.
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Explain how and why resonance is likely to be involved in a patient with a neuromotor condition such as dysarthria or apraxia
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Neuromotor conditions such as dysarthria and apraxia affect the strength of physical movements of the structures for speech production (e.g., the velum and pharynx). Velopharyngeal incompetence often occurs because the velum is not strong enough to meet the pharyngeal wall. The air used for speech production may escape through the gap in the velopharyngeal port, causing issues with hyper- or hypo- nasality and nasal air emission.
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Define and describe phoneme specific nasal air emission
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Phoneme specific nasal air emission is when a person who is capable of complete velopharyngeal closure in conversation, but velopharyngeal closure does not occur on specific pressure consonants. These consonants of the specific pressure are said to be "vulnerable", for they are produced as a nasal. For example, a child that attempts to produce /s/ could produce it as a nasal fricative with his/her mouth closed. Phoneme specific nasal emission is a phonological mislearning, and can continue long after a cleft has been repaired, but it is responsive to speech therapy.
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Describe the essential components to screening speech-language-communication evaluation in the team clinic and how this varies with the age of the client/patient
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1. Conduct a hearing screening and an oral motor exam (Depending on the age of the child, this may be done through observation (e.g., watching an infant feed) or conducting a formal screening) 2. Observe the child's communication acts (for prelingual children), comprehension (toddlers and older), babbling (syllable structures), and collect a language sample (if child can speak). The language sample can be used to assess the child's overall intelligibility, articulation, as well as syntax and lexicon. 3. Assess the child's voice if necessary (will allow the team to know if there are any other speech and language issues that need to be addressed by the team when planning intervention.)
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Explain the importance of a good medical and surgical history
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a. A good medical history is important because early diagnosis can help establish proper treatment and interventions for the client. The more that is known about the client as far as what various symptoms can help to identify specific syndromes. For example, identifying that someone has Velocardiofacial (VCF) syndrome will help the medical experts working with the client to check for any cardiac related problems as well as providing an understanding of why they have hypernasal speech. Overall a good medical history will help the medical team put a plan in place to assist the patient to develop as normally or typically as possible. b. A good surgical history is important because the less a person is surgically operated on, especially in the same place, the better off they are. This is true for individuals with cleft palate. Some may have had surgery where they had a straight line repair to their palate. This is the case for children who were adopted from other countries and had their palate surgically fixed before coming to the US. If they do need to be operated on again, the Furlow Z-plasty is the only surgery that can be done as a secondary repair. Another reason for a good surgical history is that once something is removed in surgery such as the adenoids, they cannot be put back. Therefore, the effects and benefits of removing tissue should be closely examined beforehand so that it has been clearly identified that surgery would be the most advantageous approach for the particular client.
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Explain the relationship between the child's overall development, speech-language development, and ability to draw conclusions about resonance in very young children
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When distinguishing between a child's overall development, speech-language development, and drawing conclusions about resonance, we would first do articulation therapy with child. Once the articulator precision is achieved, we can then begin to attempt work on resonance problems. If it is noted that a child is able to make the proper movements of their articulators to produces sounds that are still not pronounced correctly, than it can be distinguished on whether or not surgery will be needed to fix the problem. If surgery is needed, it will be in a case where the child has a physical related issue that is not able to be changed with behavioral therapy. However, if the child is stimuable for the sounds they are struggling with and are able to produce them with some oral pressure, then they would be referred for therapy instead of surgery.
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Implement a basic protocol for perceptual evaluation of speech resonance
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a. The type of resonance demonstrated by the child should be identified. i. Resonance should be described as normal, hypernasal, hyponasal, mixed, or cul-de-sac. b. If resonance is determined to be abnormal, the severity of the disorder should be identified. d. Cul-de-sac resonance and combined hyponasality-hypernasality can be evaluated as present or absent. e. Sentence repetition tasks are often used to examine resonance characteristics. i. Permit SLP to control the phonetic composition of a speech sample and thus facilitate identification of error patterns. ii. Three types of sentences are often used in repetition tasks: 1. Sentences containing only oral consonants 2. Sentences loaded with nasal consonants 3. Sentences containing no pressure consonants (baling along a three mile land on rainy island avenue)
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Identify the limitations of perceptual ratings
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a. There have been concerns relating to validity of EAI rating scales. This is because the perceptual difference between two adjacent scale numbers is not necessarily equal to the perceptual difference between two other adjacent numbers on the scales. b. The cul-de-sac test is not useful for small children who do not sound hypernasal in conversational speech. c. Some children are embarrassed of the procedure involving the cul-de-sac test. d. The cul-de-sac test is only sometimes useful and can't be relied upon to provide valid data.
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Identify clinical factors that influence recommendations for instrumental assessment of VP function
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When to Refer for Instrumental Assessment: 1. Client must be able to articulate words accurately to do nasometry. 2. To evaluate resonance; if this is not a concern do not refer. 3. If you hear nasal air emission but don't see it. *Be cautious with referrals; focus on getting the PLACE of articulation right and the client might not need surgery Why assess instrumentally: 1. For things we can't pick up on perceptually. 2. Might be good for showing norms for surgery. 3. Formalized way of comparing data 4. With some instruments, able to see structures and if they are capable of getting closure. 5. May help decide whether to proceed with surgery or therapy.
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Nasometry
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microphones positioned in front of the nose and mouth measure the amount of nasality during speech. A nasalance score is obtained to see if further testing or treatment is needed.
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Videofluroscopy
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Procedure that uses x-rays to acquire moving images of the internal structures of a client through the use of a fluoroscope (x-ray source and fluorescent screen)
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Aerodynamic assessment (pressure flow)
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a pneumotchygraph (measures airflow on expiration) and pressure transducers simultaneously measure oral air pressure, nasal air pressure, and nasal air flow in order to estimate VP area. One catheter is placed in a plugged nostril, another is placed in the mouth, and the pneumotchygraph is connected to the right nostril and collects airflow through the nose. *See picture on p. 306.
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Nasoendoscopy
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Procedure in which an endoscope (an insertion tube, viewing lens, and fiber optic light cable) is passed through the nose to view velopharyngeal structures.
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Nasometry Advantages and Disadvantages
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Advantages: not invasive inexpensive Disadvantages: not objective-open to interpretation by clinician
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Videofluroscopy Advantages and Disadvantages
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Advantages: Provides multiple views of the velopharyngeal valve (base, lateral, and frontal) Disadvantages: Exposure to radiation
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Aerodynamic Advantages and Disadvantages
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Advantages: Estimates velopharyngeal area Non-invasive Disadvantages: Calculations of total areas of ports of the same size but of different geometric shapes may vary from each other (book p.310) Little normative data for children under 6 years old
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Nasoendoscopy Advantages and Disadvantages
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Advantages: Movement of lateral pharyngeal walls can be assessed accurately. People can talk normally during procedure. Disadvantages: Invasive
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Identify goals of early (infant) intervention, including prevention, that are based on evidence from the literature. Pg 321-322 (Shortened list on page 322)
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a. First and foremost is parent education in regards to the impact that a cleft has on a child´s oropharyngeal mechanism and how this may be expected to affect the child´s early communicative efforts and speech production performance after palatal surgery b. Encourage aggressive language stimulation c. Engage the child in vocal play and babbling games just as they would with any infant d. Nasal consonants and glides will be more easily and readily produced than pressure consonants. e. Approximations of pressure consonants should always be accepted despite any distortion that may be present f. Compensatory misarticulations, particularly aberrant glottal behaviors, should be avoided by not repeating them to the child. g. Reinforce the baby´s efforts to vocalize by producing a babble or word that contains desired consonants h. Monitor and record the different consonants that the child produces i. Increase consonant inventory and range of syllable shapes j. Focus first on nasals and stops
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Explain the importance of differentiating functional (behavioral) speech patterns from organic and neurologic limitations in designing a treatment plan.
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a. You must know when it is appropriate to initiate speech therapy, when it is appropriate to refer for physical management, and when it is prudent to defer management of all kinds. b. Children with cleft palate require surgical and dental management to establish a mechanism that is adequate for normal speech production. For some children, these treatments alone are sufficient and normal speech develops; other children demonstrate disordered speech. Pg 341 c. It is important to establish stop production if the child is making no effort to produce these sounds in order to obtain some preliminary information about the child´s ability to achieve velopharyngeal closure. Pg 322 (probe for stimulability)
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Define obligatory speech errors and the contribution of dental malocclusion to speech production errors
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Obligatory speech errors: Errors of distortion where function (articulation) is normal, but structure is abnormal. Contribution of dental malocclusion: some children with severe malocclusions will not be capable of producing certain consonants using standard articulatory placements. For example, rotated anterior teeth and ectopic teeth may contribute to oral distortion of fricatives and affricates. Pg 326
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Explain why blowing and other non-speech exercises are not useful for most children with oral clefts
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Pg 325-326: Blowing tasks are useful with Young children in teaching the concept of oral air flow. However, they are not very useful in teaching consonant production or in improving velopharyngeal function. Oral motor exercises are introduced on the assumption that lack of oral articulation reflects an underlying problem with muscle strength. Unfortunately, the majority of children with cleft palate do not benefit from these treatment strategies because there is no underlying neuromotor problem to begin with.
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Describe the relationship between articulatory precision and speech resonance patterns
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a. The initial goal of therapy for the majority of children will be correct articulatory placement. VPI can certainly prevent a child from producing a consonant with adequate oral pressure, but it should not prevent a child from attempting an oral constriction to begin with. Pg 325. b. The SLP may discover that the resonance problem is a learned behavior and not an obligatory consequence of VPI. (For example, the SLP may find that focus on articulation may result in the VP ¨kicing into gear¨ and leave the child with normal resonance.)
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Develop a treatment plan for a toddler with an oral cleft and "typical" speech-language needs in therapy
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Toddler and Toddler: A primary role is parent education so the parent knows what to expect of their child. Encourage aggressive language stimulation following palatal surgery. This is not to say that prior to surgery parents should not communicate with their child. Parents should be encouraged to engage their child in vocal play and babbling games and should accept approximations and distortions of consonants. Compensatory misarticulations should not be reinforced. Focused stimulation and enhanced milieu training are strategies used during early stages of speech language acquisition to facilitate vocabulary expansion and increase consonant inventories for children who have a repaired cleft palate.
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Develop a treatment plan for a school age/older clients with an oral cleft and "typical" speech-language needs in therapy
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School Age/Older Clients: Due to persisting VPI, dental occlusal problems or sever craniofacial abnormalities, some patients may still have speech difficulties when they are older. SLPs must decide whether learned compensatory behaviors used to produce intelligible speech will be effectively modified in therapy or if the patient's speech is as proficient as it can be. Because articulation therapy is likely to be ineffective, biofeedback therapy, such as electropalatography (EPG) and nasopharyngoscopy, may be used. i. EPG utilizes a custom-fit acrylic palatal plate embedded with electrodes that are exposed to the lingual surface. When the electrodes are contacted by the tongue, a signal is sent to an external processing unit providing real time visual feedback. Due to the expenses involved, EPG should be reserved for patients who are highly motivated and did not benefit from more conventional therapies.
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Develop a treatment plan for a child with phoneme-specific nasal air emission and "typical" speech-language needs in therapy
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Phoneme Specific Nasal Air Emission: SLPs should address phoneme specific nasal air emission intensively on a short-term basis. A facilitating sound with the same articulatory placement that does not have nasal air emission is used to elicit oral production of the target sound
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Describe low-tech, biofeedback, and instrumental techniques for targeting resonance
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Low-tech biofeedback techniques include the See-Scape and The Oral and Nasal Listener. The See-Scape provides visual feedback of nasal air emission when the tube is placed in the client's nose. However, the clinician is likely trying to reduce nasal air emission and elicit oral production of phonemes so it is important to avoid reinforcement of nasal air emission. Some SLPs might put the tube in the client's mouth to provide visual reinforcement of orally produced sounds. The Oral and Nasal Listener is similar to a stethoscope that allows the client and SLP to hear nasal or oral sounds. This provides auditory feedback for the client and SLP rather than visual like the See-Scape.
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Z-Plasty
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Recreates the palatal sling or the muscles that lift the palate by Benefit - does not compromise the nasal air passage; approximate what would have been there, if the cleft hadn't occurred. Disadvantage - better for a smaller gap than a larger gap between velum and posterior pharyngeal wall.
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Pharyngeal flap
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When a portion of the posterior pharyngeal wall is connected to the velum to create a small opening. Benefit- helps velum more accurately, leave 2 openings, can be removed if causes problems Disadvantage - can create hypo nasal speech, occludes the airway, can cause sleep apnea and snoring
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Sphincter pharyngoplasty
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When portions of the lateral pharyngeal wall and posterior laryngeal wall are adjusted to create a smaller opening Benefit - good for children with good velar motion and helps those with too much depth Disadvantage - can create sleep apnea
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Describe the time course for resuming speech therapy after surgery and evaluating the efficacy of the procedure
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6-12 months should be given to allow the child to adjust to the new mechanism, before another surgery is considered. Secondary management should result in elimination of hypernasality and audible nasal emissions. If it does not, then a secondary surgery should be considered.
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Describe the basic structure and function of prosthetic management techniques and when these are likely to be used: obturation and palatal lift
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Obturation - used when the palate is too short to to adequately close the velopharyngeal port completely. It has a posterior extension from an anterior oral plate, with the bulb on the extension and fills the gap between the velum and the lateral walls during speech Palatal lift - rigid arms that lifts the velum, so that closure can be more easily obtained. Used for patients that do not have as much movement, but must still have some movement
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Describe what cancer is
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Cancer is a term used for diseases in which abnormal cells divide without control and are able to invade other tissues. Cancer cells can spread to other parts of the body through the blood and lymph systems. Malignant tumors are cancerous. Cells in these tumors can invade nearby tissues and spread to other parts of the body. The spread of cancer from one part of the body to another is called metastasis.
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How stages of cancer are described using the TNM staging system
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Stages of cancer are described using the TNM staging system: T = extent of the primary tumor N = state of regional lymph nodes M = metastases c. Tumor Staging: (T) Tis - Preinvasive cancer (carcinoma in situ) T0 - No evidence of primary tumor T1 (T1a, T1 b) - Mobility is normal; Tumor is confined to one vocal cord (1a) or both vocal cords (1b) T2 - Vocal cord mobility or extends from the vocal cords to supraglottic or subglottic area or impaired T3 - Tumor is confined to the larynx with fixation of the vocal cord T4 -There is invasion through thyroid cartilage and/ or other tissues beyond larynx (e.g., trachea, thyroid, pharynx, soft tissue of neck). Tx - Minimum requirements to assess primary tumor cannot be met Lymph Involvement: (N) N0 - No evidence of regional lymph node involvement N1 - Evidence of involvement of movable homolateral regional lymph nodes N2 - Evidence of involvement of movable contralateral or bilateral regional lymph nodes N3 - Evidence of involvement of fixed regional lymph nodes Nx - Can't stage Metastases (Spread): (M) M0 - No evidence of distant metastases M1 - Evidence of distant metastases Mx - Minimum requirements to assess the presence of distant metastases cannot be met
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Signs and symptoms of oral cancer
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Intraoral lesion Intraoral pain Dysphagia Mass in neck Weight loss Persistent sore throat
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Signs and symptoms of laryngeal cancer
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Voice change - hoarseness Chronic cough, throat clearing Pain on swallowing Weight loss Ear pain Difficulty breathing or stridor Neck swelling or lump
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Demonstrate understanding of the major anatomic and physiologic changes associated with treatment for laryngeal and oral cancers that use surgical excision, radiation and chemotherapy
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Side-Effects of Treatment: Surgery: Absent structures Sensory - motor changes Radiation therapy Tissue stiffening - decreased mobility Fatigue Chemotherapy Loss of sensation Combined therapy approaches
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Describe the role of the speech-language pathologist in pre-surgical counseling and intervention with individuals with head and neck cancer
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Pre-surgical: The SLP's role is to prepare the patient for what is to come. This involves explaining that the voice will no longer be there, but that they will be able to use other forms of communication. The SLP needs to show pictures and emphasize the difference between voice and speech All of the other options should be discussed with the patient pre-surgically while the patient is still able to talk about what will happen. Patient preferences will vary based on lifestyle, so it is very important that they are able to get all the details about what will be the best option. Patients should always have more than one way to communicate, e.g. esophageal speech along with an electrolarynx, in case one doesn't work correctly, so the SLP needs to communicate this as well. The SLP should also create a simple AAC device with the patient for him or her to use immediately post-surgery to communicate physical needs before actually learning to use their new chosen form of communication (like tracheoesphageal speech.) Also get a good idea of the person's literacy pre-surgery - this is very important when helping them decide what kind of communicative strategies will work for them and their family.
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Describe the role of the speech-language pathologist in immediate post-surgical counseling and intervention with individuals with head and neck cancer
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The SLP would check on the patient's swallowing abilities to make sure they can eat/drink well enough to leave the hospital and would remind the patient to use the AAC device they created together before surgery. Help them with basic communication needs to tell someone they're hungry, thirsty, in pain, etc.
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Describe the role of the speech-language pathologist in immediate long-term counseling with individuals with head and neck cancer
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The SLP may be needed to help replace tracheoesophageal valves as needed. They also may counsel the patient about other options for communication as needed
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AAC for communication after total laryngectomy
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AAC: This could be either high-tech (iPad or specialized computer device) or low-tech (pen/paper, picture communication board). Advantages: doesn't require surgery or insertion of valve, low-tech wouldn't need batteries. Disadvantages: most different from the oral communication that the patient is most familiar with. Depending on type, AAC could be difficult for patient to use with some populations, such as children or people with cognitive issues.
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Electrolaryngeal Speech for communication after total laryngectomy
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Use of a vibrating source (electrolarynx) that is held on a part of the resonators - can be the throat or cheek, wherever there is the most vibration. This spot can vary from person to person. Advantages - no secondary surgery required, devices often paid for by phone company. Disadvantages: has a very monotone sound and not a big distinction between voiced and voiceless sounds, so these users can have reduced intelligibility especially for unfamiliar listeners. Have to learn to use and to take pauses such as when they used to breathe during normal speech, and to diminish rate of speech and increase amount of enunciation - land on specific articulation targets so it sounds clear.
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Tracheoesophageal Speech for communication after total laryngectomy
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A valve is placed in a fistula between the back wall of trachea to the esophagus. Patient blocks off stoma to send air from the lungs through the valve, where the air vibrates in the upper 1/3 of the esophagus, creating a sound source which is then shaped by the articulators and resonators to create speech. Advantages - no device to carry around, speech sounds closest to normal, good amount of words per breath because patient can use entire lungs' worth of air for speech, similar to normal speaking. Feels like speech to the patient. Ability to have some intonation changes, increasing intelligibility. Disadvantages: Supposed to be a one-way valve, but this can fail and allow food/drinks to go through the wrong way. Secondary surgery required usually to create opening between esophagus and trachea. Occasionally this can be done during primary surgery, but structures move around during healing so it often has to be done later. Valves only last 3-4 months max (sometimes much less) so they have to be replaced by SLP or patient. Radiation could cause tissue to be unable to vibrate. Patient has to be competent to care for the valve. If prosthesis falls out, it's an emergency - must thread tube in to keep the hole open immediately and then need to get new prosthesis placed as soon as possible.
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Esophageal Speech for communication after total laryngectomy
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The patient gulps air down into the upper one third of the esophagus and the forces it back up, causing the esophageal tissues to vibrate, creating sound that can then be shaped into speech. Advantages: no secondary surgery, no device to carry around, no batteries needed, no valves to replace. Disadvantages: Sounds rough, not many words per breath because of low air volume that can be taken in. Pauses between phrases to gulp more air. Would not be a good option if excess radiation has tightened muscles. Has the same sound source as tracheoesophageal speech but the air source is what's different.
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Total laryngectomy:
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The larynx is completely REMOVED. These patients would have a stoma (open hole) in the front of their neck. They will not be able to speak using their larynx ever again, but there are many other options for communication. Much more common in adults than in kids. Don't sit directly in front of them! NO risk for aspiration because liquids/foods are going down a completely separate pathway.
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Tracheotomy:
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These patients still have their larynx, but some sort of blockage requires a trach tube to be placed in the neck below the larynx. With these clients, you would see the white trach tube often held on with a neck strap - would not just be an opening! (That's a stoma, only in total laryngectomy.) Trachs are often temporary, unlike total laryngectomy. When a child has a tube in their neck, it's very likely to be a tracheotomy tube. These clients can speak with a speech valve (Passy-Muir Valve)- they would breathe in through the trach and then the valve doesn't allow the air back out the trach tube, but rather forces it up through the vocal folds for speech. If there is a complete blockage/obstruction this couldn't be used because the patient wouldn't be able to breathe out. Don't sit directly in front of them! Risk for aspiration is still there with a trach because the airway and esophagus are still connected. With an inflated cuff on a trach tube - can't use speech valve!
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Describe, in very basic terms, the implications associated with chewing and swallowing for each type of treatment for head and neck cancer
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a. Surgery: absent structures leading to possible food regurgitation when turning upside down b. Radiation Therapy: damage to healthy surrounding tissue; tissue stiffening leading to decreased mobility swallowing or chewing; damage or breakdown of oral tissue; taste changes c. Chemotherapy: breakdown of cells in the oral cavity and GI tract; nausea; weight loss; loss of sensation; taste changes d. Combined Therapy Approaches (i.e. surgery & radiation, radiation & chemo, or all three— not surgery & chemo)
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Explain the advantages (importance) of interdisciplinary team care for individuals with head and neck cancers.
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a. An interdisciplinary team may include head and neck surgeon, reconstructive surgeon, dental surgeon, and specialists in radiation oncology, medical oncology, medical imaging, clinical pathology and laboratory medicine, pain palliative therapy, nutrition, speech therapy, nursing, and social work. Specialists in newer disciplines such as molecular biology and nuclear imaging are also joining such teams. b. It is advantageous to have an interdisciplinary team when dealing with individuals with head and neck cancers because every specialist brings different knowledge to the situation. As an SLP, it is important to be in communication with the surgeons or treatment specialists, such as a radiation oncology specialist. In order to provide the proper care for our client during the pre-treatment, immediate post-treatment, and long-term post-treatment stages, we need to be aware of the decisions the patient has made regarding treatment and be in discussion with the client about potential side effects, as well as modes of communication the patient may be needing to use to communicate with others. The other specialists on the team need to all be aware of the patient's choice for treatment, as well as how to best communicate (e.g. after surgery).
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Prelinguistic findings of children with clefts
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b. (From text, p 232) Compared with age-matched peers without clefts, infants with clefts: i. Vocalize as frequently ii. Have a more restricted consonant inventory iii. Produce fewer total consonants iv. Produce more glottal stops v. Produce fewer oral stops vi. Produce fewer alveolar stops vii. Produce fewer multisyllabic utterances
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Rating scales are used to determine the severity of hypernasality
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i. Equal-appearing-interval scales (EAI) ii. Usually contain 5, 7, or 9 points iii. The upper-most point is indicative of the most severe form of hypernasality iv. When rating scales are used, it is most important to focus on the underlying descriptors (mild, moderate, severe) associated with the numbers than the numbers themselves. v. If hyponasality is present, it can be rated on a three point scale.
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Cul-de-sac test (aka hypernasality test and hyponasality test)
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Involves compressing and releasing of nares during speech and listening for a shift in resonance when the nares are occluded.
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To detect hypernasality
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Have patients repeat a series of 10 words beginning with /b/. Each word is produced first with the nares occluded and then with the nares pinched. ii. If hypernasality is present when the nares are unoccluded, a shift to cul-de-sac resonance will be heard when the nares are occluded.
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To detect hyponasality
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To detect hyponasality: i. Production of speech with words beginnings with /m/. ii. If hyponasality is present, no difference in resonance should be perceived on these words when the nares are alternately compressed and left unoccluded.
