WMU Cleft Palate – Flashcards
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Aspects of communication "at-risk" in children born with cleft palate
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Articulation Resoance Language Hearing Voice
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Resonance Disorder
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Hypernasality Hyponasality Mixed resonance disorder
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Hypernasality
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Excessive nasal resonance during the production of speech. Does not affect voiceless consonants.
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Hypernasality affects
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vowels and vocalic consonants. Related to abnormal coupling of oral and nasal cavities.
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Hypernasality can be due to
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VPI Oronasal fistulae Unrepaired cleft palate
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Hyponasality
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Reduction in normal nasal resonance
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Hyponasality is due to
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Insufficient nasal airflow during target nasal sounds. Generally caused by blockage in the nasopharynx or obstruction in the nasal cavity. Particularly affects /m/ is /b/ and /n/ is /d/.
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Cul-de-sac resonance
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Type of hyponasality
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Cul-de-sac
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Anterior nasal obstruction "Muffled" quality
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Mixed resonance disorder
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Hypernasality and hyponasality co-exist Not uncommon in cleft palate population Hyponasality can mask hypernasality
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Possible Causes of Resonance Disorder Hypernasality
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Structural: Velopharyngeal Insufficency Functional: physiological, e.g. dysarthria Learned Non-cleft palate VPI
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Possible Causes of Resonance Disorder Hyponasality
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Usually structural: polyp, deviated septum, other nasal airway structural abnormalities, allergic rhinitis, enlarged adenoids
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How to evaluate resonance?
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Perceptual judgement Problem: experience, reliability Training/educational materials Calibration
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Speech materials needed to evaluate
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Sustained vowels, CV syllables, single words, sentences, conversational speech
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Speech materials needed to evaluate continued
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High vs. low pressure consonants High vs. low vowels Oral vs. nasal consonants
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How to rate resonance
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Normal vs. abnormal hypernasal, hyponasal, mixed Severity (mild, moderate, severe) Consistency
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Nasal emission
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Inappropriate release of air pressure through the nasal cavity during speech. Related to VPI, often co-exists with hyper nasality. Audible or inaudible (visible) nasal escape during production of speech only affects consonants, esp. pressure consonants. Affects articulation and not resonance.
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Phoneme-specific nasal emission
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Learned articulatory error (pattern) Not due to physical cause Normal resonance (no hypernasality) Nasal emission during production of some but not all pressure consonants Can accompany or replace target pressure consonants
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Phoneme-specific nasal emission treatment
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Never surgery always speech therapy. Usually traditional articulation therapy
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Nasal turbulence
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NE + some intranasal resistance to airflow
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Low-tech, no-tech evaluation of resonance and nasal emission
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Cul-de-sac test Modified tongue-anchor technique Mirror See-scape Nasal tube/stethescope
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Cul-de-sac test
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Listen for shift in resonance when nares are occluded "pinched" vs. unoccluded. If sounds hyper nasal when unoccluded, cul-de-sac resonance when occluded then hyper nasal.
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Modified tongue anchor
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Useful for detecting nasal emission. Suggestive of VPI and/or Oral-nasal fistula Puff up cheeks with lip seal
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Mirror
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Hold under alternative nostrils during production of speech or non-speech tasks Fogging on mirror during production of target oral stimuli indicates inappropriate nasal escape suggestive of VPI/fistulae
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Mirror continued
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One disadvantage is some oral airflow during production of vowels may be normal, need to control speech stimuli carefully (sustained /s/ air should not escape)
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See scape
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Simple commercial device comprising piston inside clear vertical tube. Probe tip at end of flexible tube can be placed in nostril. Nasal airflow can be seen by rising piston.
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See scape advantages and disadvantage
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Advantage: inexpensive and provides clear visual feedback. Disadvantage: not reliable enough to quantify severity or progress. Also can be affected by humidity. Detects airflow by nasal emission. It does not detect hyper nasality.
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Evaluating Articulation
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Loaded with high-pressure consonants (plosives, fricatives, affricates)- vulnerable in cleft populations
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Evaluate across contexts
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Single words, sentences, conversational speech, isolated phonemes and CV syllables. Evaluate stimulability
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Possible contributors to articulation disorder in CL+/- palate
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VPI Oral-nasal fistula Abnormal dentition/occlusion Hearing impairment Mislearning- related to history of structural (backing) abnormalities or can be unrelated to cleft Substitutions and omissions are more often than distortions
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Possible consequences: VPI
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Hypernasality, nasal emission, compensatory articulations
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Possible consequences: oral-nasal fistula
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Nasal emission Hypernasality Middorsal palatal stop
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Possible consequences: abnormal dentition/occlusion
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Articulatory distortions Oral substitutions
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Possible consequences: hearing Impairment
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Hyper/hyponasality Voicing errors placement errors
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Possible consequences mislearning
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Related to history of structural abnormalities Unrelated to cleft
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Common error patterns
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Substitutions and omissions more common than distortions Pressure consonants more vulnerable than non-pressure consonants
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Common error patterns continued
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Place errors more common than manner errors (but nasalization) Backing
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Compensatory articulations
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Glottal stop Pharyngeal fricative Laryngeal fricative Pharyngeal stop Pharyngeal affricate, Velar fricative Posterior nasal fricative Middorsum palatal stop
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Compensatory articulations continued
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Develop in compensation for VPI (or for palatal fistulae, malocclusion) Unconscious attempt to block air escaping through VP port; create pressure valve at /near VP port
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Submucous Cleft Signs
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Bifid Uvula Zona Pellucida (blue-tinged mucousa) Posterior nasal spine notching Lateral levator bulges Nasal regurgitation with liquids Occult cleft absent musculus uvulae
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Primary manifestations of VFD
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Nasal regurgitation Inappropriate air flow Nasal rustles/turbulence Hypernasal resonance Compensatory misarticulations Poor speech intelligibility
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Secondary Manifestations
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Nasal grimace Hoarseness Vocal cord nodules Short utterances Soft voice syndrome
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High pressure consonants
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p,b,t,d,k,g,s,z, sh, ch,
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Low pressure consonants
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r,l,w,h,j, and vowels
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Phoneme specific nasal emission
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Never do surgery always speech therapy
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Cul de sac testing
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produce the oral words/sentences with the nose open and then with the nose closed. If normal resonance will be identical for both productions.
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Passive/obligatory errors
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Hypernasality, nasalized oral consonants, weak pressure consonants. Disappear when the structure is corrected.
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Active/compensatory errors
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Glottal stops. Active attempt to compensate for structural deficit. Persist when structure is corrected.
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VP insufficiency Action Required
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Surgery
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VP incompetence/dysfunction: Inconsistent closure
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Speech therapy
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VP incompetence/dysfunction : Never closes
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Palatal lift or surgery
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Surgical Management is indicated for
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Hypernasality caused by structural or physiological abnormality Moderate to large velopharyngeal gap Velopharyngeal insufficancy Hyponasality
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Blowing exercises
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Do not improve velopharyngeal strength
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Resonance therapy techniques: Auditory discrimination
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hypernasality audible nasal turbulance nasal snort hyponasality
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Resonance therapy techniques: Exaggerated articulation
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Increasing ROM of the articulators assist with increasing palatal closure with increased muscle recruitment. Generally slow down rate of speech to improve velopharyngeal closure and coordination.
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Resonance therapy techniques: Visual Feedback
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See-scape or nasal mirror Nasometer Biofeedback nasoendoscopy
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Resonance therapy techniques: Auditory training
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Stethoscope Microphone Listening tube Cul-de-sac training- match oral productions with and without nares pinched.
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Therapy note
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If persisting hyper nasality or nasal emission persists after a few months of therapy the child should be refereed to a specialist for further testing. Don;t keep asking the child to perform something they are unable to do.
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Articulation therapy
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Should be used even if surgery is still needed to reduce velopharyngeal dysfunction or a oronasal fistula.
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Phoneme hierarchy
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Train from sounds before back sounds because they are easier to see. Voiceless before voiced. Work with sounds the child can produce to identify target sound selection.
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Therapy techniques
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Whispering (eliminates glottal stops) Forward tongue placement Pair /h/ with target phonemes
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Craniofacial team includes:
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Plastic surgery Maxillofacial Surgery Orthodontics Pediatric dentistry Prothodontics Speech Pathology Audiology Social Work Psychology Genetics Dietitian Nursing Neurosurgery Otolaryngology Coordinator
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Muscles
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Palatine aponeurosis Tensor veli palatini Levator veli palatini-muscle repaired at the time of surgery. Palatoglossus Palatopharyngeus (palatothyroideus) Musculus uvulae Superior constrictor lateral wall movement
