Resonance Treatment 4/2

palatal obturator

covers a palatal defect such as a fistula

speech bulb obturaror/pharyngeal obturator

if velum is too short, the bulb fills in the gap

• Extends all the way into VP port and plugs the hole in VP

mechanism

• Not commonly used in children as tolerance is an issue

• Are more common in cancer patients who have had tumor

resections or radiation

• Must be removed at night to prevent sleep apnea

palatal lift

elevates a passive velum to hold it against the posterior pharyngeal wall

• Does not add length or fill in the gap

• Indicated for VP incompetence = when there is adequate length

but inadequate movement

• Short lift may be used at first, and it can be lengthened as patient

begins to tolerate device

• If patient has lateral pharyngeal wall movement, they may be

able to have a small gap for nasal sounds while still achieve full

closure for oral sounds

• More commonly used in adults with neuromuscular disorders who

are experiencing velar paresis or paralysis

obturator

• Covers a palatal defect such as a fistula

• Does not typically extend past soft palate

• Used in children waiting for fistula surgery

• Used if multiple fistula surgeries fail

• Can be combined with dentures if needed

prosthetic devices for dentition

improve aesthetics, mastication, and speech productiond

dentures

replaces all teeth on a dental arch

overlay dentures

fit over existing teeth

fixed bridge

replaces small dental segments

nasoalveolar molding (NAM) for cleft lip/palate

makes it much easier for surgeon as tissues are brought into alignment prior to surgery

• improved symmetry of patients face post surgery

prosthetic device for the face

• Molds can be made from

nonaffected side of face or a

family member’s face

• 3D printers can produce

prosthesis

Osseo-integrated implants are

used to attach prosthesis to face

• Basal cell carcinoma:

resected maxilla, palate,

nasal pyramid, zygomatic

arch

• Unable to speak, eat or drink

feeding a baby with a cleft

• Dr. Brown’s Special Feeder

• Infant Paced Feeding Valve is inserted into any level Dr. Brown’s

standard silicone nipple to create a compression nipple

• When used in combination with Dr. Brown’s Natural Flow bottle

system, assists infant in self-regulation during oral feedings

• Dr. Brown's Natural Flow bottle is fully vented to create a

positive-pressure flow for vacuum-free feeding

when to recommend speech prosthetics

• If VPI surgery must be delayed for a prolonged period of time

• If VPI surgery was attempted, but failed

• If fistula surgery was attempted, but failed

• Cancer caused resection of portions of the oral cavity and too much

tissue was removed to reconstruct those areas.

• Neuromotor disorders: surgery is often not recommended in cases of

degenerative diseases

• If the patient is too elderly or fragile for surgery

• Note: speech therapy may still be needed to correct speech

production or re-train swallowing after the prosthetic has been fitted

• Prosthetics should never be used to attempt to “cure” VP function

• They will not train VP mechanism to work better

• They are a compensatory or coping mechanism

ST for patients w/ cleft palate

• The primary focus of speech therapy will be articulation

• These patients tend to develop misarticulations as a result of their

incorrect anatomy and physiology = compensate by producing the

closest thing they can

• After the anatomy and physiology are corrected via surgery or

prosthetic devices, the articulations do not usually self-correct (the

errors are habituated)

• Speech therapy needs to teach the correct placement, manner, and

voicing of production of articulation

• For cancer patients, their oral anatomy/physiology may never be

exactly the same, so they have to learn to speak with the new anatomy

and physiology

• Some patients (especially adults) have difficulty learning to speak with a prosthetic device, and so require speech therapy

assessment for pt with cleft

• Administer a standardized articulation assessment

• Conduct any instrumental assessments needed (see previous

lecture)

• Categorize every misarticulation as:

• Developmental errors (for pediatric patients)

• Obligatory distortions

• Compensatory errors

• Then, SLP can determine what sounds to target, in what order,

and how to target each one

ST vs Physical Management

• Obligatory distortions: require physical management before ST

• Compensatory errors: require physical management with ST

• VP Mislearning: no physical management required, only ST

• Before corrective surgery: can always work on placement (and

possibly manner), but perfect speech not attained until after

surgery

• If surgery is soon, best to delay ST because ST will go faster,

be easier, and make better progress after surgery

• After corrective surgery: must train proper use of corrected

anatomy since learned misarticulations must be trained out

• When in doubt, do trial ST for 4-6 weeks to see if surgery is

needed or not

motor learning

process of acquiring new motor skill thru direct instruction and constant feedback

motor memory

developing automaticity of newly learned motor movement through repetition- depends on frequency and intensity

motor memory and motor learning require_____

REPETITION

principles of speech therapy

• Do discrimination training first (for pediatrics)

• Establish placement before manner of production

• Follow the articulation hierarchy - always use 90% accuracy

• Use /h/ to transition from the voiceless consonant to the vowel

• After initial position, determine if medial or final is easiest to do

next

• For medial position, break the word up into syllables

• For final position, break the word up to separate the final

consonant from the preceding sounds

biofeedback

• Technique for making unconscious or autonomic physiological

processes perceptible in order to manipulate them under

conscious control

• Assumes a desired response can be learned when it is

determined that a specific thought process can produce the

physiological response

• Feedback can be auditory, visual, or tactile-kinesthetic

• Biofeedback can be low-tech or high-tech

• Patient must be old enough to understand and comply

low-tech biofeedback

• Straw

• Toobaloo

• Air Paddle

• Mirror

• See-scape

high-tech biofeedback

• audio recordings

• nasometer

• pressure-flow instrumentation

• nasophayngoscopy

controversial procedures

• resistance training against positive airway pressure

prosthesis reduction therapy: gradually reducing size of prosthesis to promote VP strength and movement

infant st goals for cleft palate

feeding, oral sound play (discourage pharyngeal sounds)

toddlers st goals for cleft palate

language development is primary

• Promote oral sounds too

preschool ST goals for cleft palate

intelligibility

• VPI management'

  • articulation therapy

school age st goals for cleft palate

• Goal is age-appropriate speech by kindergarten

• Finish up any lingering compensatory errors during school age

adolescence

final surgery should resolve lingering obligatory distortions

goals for non-cleft resonance diagnosis (pediatiric)

• Determine cause for the resonance disorder

• Deep pharynx

• Velar paresis/paralysis

• Etc.

• Recommend surgery if patient is a candidate

• Fit a prosthesis if not a surgical candidate

• Speech therapy for compensatory errors or mis-learning

goals for adult neuromotor

• Maintain intelligible verbal communication as long as possible

• VPI surgery may be considered in:

• Relatively younger patients

• Stable, nondegenerative patients

• Prosthetics may be preferred in:

• Older patients

• Medically compromised patients

• Progressive, degenerative patients

• Tumor resections with insufficient tissue to reconstruct

• Articulation therapy if indicated

therapy for VPI due to apraxia

• Apraxia of speech can cause VPI - usually with alternating,

inconsistent, and unpredictable hypernasality and hyponasality

• Apraxia of speech affects children and adults

• AOS does not need surgery or prosthetics

• AOS needs intensive speech therapy

• Use standard AOS techniques taught in Articulation and

Phonology courses

• Hundreds of repetitions using principles of motor learning