Cleft Lip and Palate

Craniofacial structure gestational development

4-7 weeks

Primary

lip, alveolus, hard palate

Secondary

Hard palate and soft palate

Isolated

Lip or palate

Combination

Both lip and palate

Complete

Extends entire length of palate (extending to nose)

Incomplete

Cleft does not extend into the nose

Overt palatal cleft

-Visibly open
-can be observed via intra-oral inspection

Submucous cleft

-Cleft is covered by mucous membrane that lines the roof of the mouth

Sound-production errors

-sensory-motor based phonetic errors (incorrect tongue placement due to mislearning)
-linguistic-based phonemic errors (incorrect sound production/ linguistic rule application due to mislearning)
-Errored pressure sounds

Velopharyngeal insufficiency or dysfunction

opening between the mouth and nose is not closed properly

Hypernasality

excess nasal resonance on vowels/voiced sounds

Hyponasality

little to no resonance on nasal sounds

Cul de sac resonance

-sound is muffled due to some obstruction ("foot in mouth")
-enlarged tonsils

Obligatory errors

-structural abnormality results in speech errors
-fix structure BEFORE therapy
-result of velopharyngeal insufficiency

Compensatory errors

-incorrect placement compensates for structure
-traditional speech therapy
-if errors are inconsistent, this is a result of mislearning

Common compensatory errors

-glottal stops
-pharyngeal fricatives and stops
-nasal fricatives
-mid-dorsum palatal stops

Evaluation

-Nasal flutter test
-mirror test
-reading lists

Nasal flutter test

-pinch nose during prolonged vowel
-if difference in resonance it indicates a VP deficit

Reading list

-read a list of minimal pairs
-observe hyper/hyponasality

Treatment approaches

-auditory discrimination
-phonetic placement
-multimodal cueing

3-6 months

repair cleft lip

6-12 months

repair cleft palate

12+ months

-SLP Tx
-Note: speech therapy can begin before surgery, but you cannot fix obligatory errors

6-11 years

orthodontic interventions

Birth-22 years

-ongoing tx and management

8 months

Every child born with cleft palate should be evaluated for language and speech development by this age if not sooner

2 big concerns for cleft lip/palate intervention

1. correct articulation (not glottal stopping)

2. Correct oral sounds (not nasal emission)

Glottal stops

-/ʔ/
-if glottal stops emerge early, can be eliminated through treatment
-easier to eliminate if treated earlier than once they become established in the child's system
-once engrained, not likely to eliminate

Intervention for infants and toddlers

-driven by child's speech/language NOT the dx of cleft
-naturalistic
-family-centered
-include parent training

Speech therapy tips

-ignore the obligatory distortions during therapy
-focus on placement, pressure/airflow, manner, and voicing (and lang. as needed)

Treatable

-compensatory errors
-placement errors
-omissions
-backing/other phonological errors

Not treatable

-obligatory distortions
-consistent audible nasal air emission (present across virtually all sounds)
-consistent hypernasality
-weak pressure consonants
-some articulatory distortions secondary to malocclusion

collaborate with cleft team to determine what should be targeted in therapy and what requires medical/orthodontic treatment

Eustachian tube dysfunction/conductive hearing loss

-children with cleft lip/palate or non-cleft VPD are at risk for this

Cul-de-sac technique

occlude nares during production of pressure consonants in order to "feel" air pressure in the mouth & create a direct airflow from the mouth

Whispered speech

-sustained /h/
-and over aspiration to break up glottal stops

Therapy principles

-only one sound is targeted and stabilized at a time in a hierarchical progression
-order: isolation, syllable, words, multisyllabic words, phrases, sentences, spont. speech
-child needs to produce the sound with 90% accy. during spont. speech before moving to next target

Target sound selection: where to start?

-start with sounds causing the most negative impact on intelligibility
-often compensatory errors
-target sounds for which the child is stimulable
-keep development in mind, but ok to deviate

An effective way to assess VP dysfunction

-ask the client to repeat sentences/words with high pressure oral fricative and consonants

Tensor Veli Palatini

-muscle that dilates the eustachian tube
-presence of cleft palate distorts this function, resulting in conductive hearing loss

Etiologies

-genetic disorders
-chromosomal aberrations
-teratogenically (environmental teratogens)
-mechanically induced abnormalities (uterine tumor)

Phonemes commonly affected

-s, z, th, ch, ts

Velopharyngeal valve/closure

-closes off nasal cavity from oral cavity during speech
-closes for oral sounds, opens for nasal sounds
-important for pressure-sensitive sounds (plosives, fricatives, affricates)
-closes off nasal cavity during swallowing, vomiting, blowing, sucking, and whistling

Articulation/learning

VP mislearning

Anatomy/structure

VP insufficiency

Physiology/movement

-VP incompetence
-neurogenic impairment, movement disorder/motor planning

Flexible fiberoptic video nasopharyngoscopy (FFVN)

-invasive procedure used to evaluate the structure and function of the VP mechanism during speech
-use high pressure consonants to determine VP adequacy

Resonance disorders

-hypernasality
-hyponasality
-cul de sac
-mixed

Speech therapy after VPI surgery

-child may continue to demonstrate hypernasality/nasal emission
-due to mislearning
-need to provide articulation tx to help child overcome mislearning

Nasometer

an instrument used to measure the acoustic energy through the oral and nasal cavities

Treating Hypernasality

-visual feedback
-ear training
-increased mouth opening
-increased loudness
-improved articulation
-decrease pitch
-change speaking rate

Treating Hyponasality

-use nasal glide stimulation
-visual aids/biofeedback
-focusing/directing tone into fasicial mask (sinuses)

General modification of resonance

-provide feedback on nasal airflow through instrumentation (mirror, nasometer, etc.)
-train patient to open mouth wider to increase oral resonance and vocal intensity
-use nasal obturator or nose clip

Common pattern of velopharyngeal closure

coronal pattern with the velum contacting the pharyngeal wall

Pierre Robin Sequence

Disorder resulting in micrognathia, glossoptosis, cleft palate, airway obstruction

Treacher Collins Syndrome

Disorder resulting in glossoptosis, micrognathia, and hearing loss

Levator Veli Palatini

Primary soft palate elevator

8 and 9 weeks

Hard palate fuses in utero

Stickler Syndrome

-most common identifiable cause of cleft palate -Characteristics include cleft palate, SNHL, progressive myopia, retinal detachment and cataracts, progressive arthropathy (joint disease).
-Craniofacialfeatures include maxillary and mandibular hypoplasia, flat midface impression, prominent eyes, long philtrum, depressed nasal bridge with epicanthal folds, cleft palate.
-Co-occur with pierre robin sequence

Craniosynostosis

-premature fusing of one or more skull bones in utero
-often associated with cleft palate