Articulation Structure - Cleft Palate

Specific structures involved with cleft palate

nose, upper lip, hard palate, hard palate, soft palate/velum, pharynx

the oral cavity includes:

hard palate, soft palate/velum, uvula, tonsils, alveolar ridge, tongue, anterior and posterior faucial pillars

hard palate

separates the oral cavity from the nasal cavity and is a boney structure, it's the roof of the mouth and floor of nasal cavity

soft palate/velum

sets just behind the hard palate and is the muscular part

uvula

the pendulous thing that hangs in back of throat - don't over look

soft palate/velum...

-this is the movable structure

-when breathing through nose the soft palate drops from hard palate and sets on the base of tongue to open pharynx to nasal cavity

-during speech it elevates and elongates to touch the pharyngeal wall to close off nasal cavity

the pharynx

-space between esophagus and nasal cavity and is divided into 3 sections (oropharynx, nasopharynx, hypopharynx)

-posterior pharyngeal wall (back of throat)

-lateral pharyngeal wall (sides of throat)

Oropharynx

posterior to mouth

Nasopharynx

posterior to nasal cavity

Hypopharynx

below oropharynx and runs from epiglottis to esophagus

Important muscles!!!

-Levator veli palatini - #1 muscle

for raising the velum, contraction moves the velum

up and back to sit against the

posterior pharyngeal wall.

-Superior pharyngeal constrictor -

moves the lateral walls in to

narrow the velopharyngeal port (in

the upper pharynx)

-Tensor veli palatini - opens and

closes the Eustachian tube

Physiological subsystems for speech

-No isolated systems ----- all work together

-Include: respiration, phonation, resonance, and articulation.

-System of valves at the following levels: glottis, velopharyngeal and oral.

-For speech to be intelligible the velopharyngeal valves must function in

coordination with these systems.

Physiology of VP valve - resonance

-Normal VP closure is completed with the coordination of velum, lateral

pharyngeal wall and posterior pharyngeal wall

-VP valve should close off nasal cavity from oral cavity during speech

-Lateral walls move in and post. wall moves forward to achieve closure

-When nasal phonemes are produced the velum is pulled down so that sound

can enter nasal cavity

Clefts are...

-4th most common birth defect

-Most common congenital defect of face

-1 in 600 live births

-Abnormal opening or a fissure in the anatomical structure that is normally closed.

-Occur during the first trimester

-Due to disruption of embryological development

Cleft lip

failure of parts of lip to come together early in the life of a fetus

Cleft palate

occurs when parts of the roof of the mouth do not fuse normally during fetal development, leaving a large opening between the oral cavity and the nasal cavity

4 basic causes of a cleft

CHROMOSOMAL DISORDERS, GENETIC DISORDERS, ENVIRONMENTAL TERATOGENS, MECHANICAL FACTORS IN UTERO (COOPER - PIERRE ROBIN - MECHANICAL)

Classification

Kernahan and Stark (1958) - classify based on embryological development and there are 2 categories - cleft of primary palate and cleft of secondary palate

Classification continued

-Primary palate - anterior to incisive foramen; includes the

lip!!!

Fuse around 7 weeks include alveolus and lip

Unilateral or bilateral

Complete or incomplete

-Secondary palate - post to incisive foramen

Fuse around 9 weeks

Include hard palate and velum

Incomplete or complete

Can be both primary and secondary!

Types of cleft lip

- Incomplete - can be just a notch in lip with alveolar ridge

intact (can go into nasal sill)

- Complete - cleft of primary palate all the way to incisive

foramen - through entire lip and alveolus

Types of cleft palate

- Incomplete - can be bifid uvula

only or farther into velum

- Complete - extends through

uvula and velum and through

hard palate (associated with

syndrome)

Submucous cleft

-congenital defect that is in the underlying structures of palate, not on the oral surface.

- Can involve muscles of SP and or boney

structures of HP

- Often occurs with syndrome

- Classic characteristic of submucous cleft is a

bifid uvula, bluish line, notable V - see pg. 64

Primary effects of cleft palate

***Development of speech is different for child with cleft palate.

-Distorted/Open environment = nasalized productions

-No place for tongue to make contact = Articulation errors

-Muscles are not connected/non-functional =Increased risk of Otitis Media, possible hearing loss which limits self-monitoring

Other effects to think about

Nasal regurgitation -> Feeding difficulties -> Middle ear disease -> Velopharyngeal insufficiency -> Language development

Early speech/language development with cleft

-Limited feedback from parents during the time of babbling.

-Babies get stuck on glottal sounds and don't move to the front of the mouth for bilabials and alveolar sounds.

-Fewer consonants, fewer multisyllabic productions, less to pull from when attaching meaning to words (vocabulary)

-Tend to stick with nasals, glides and glottals

-Parents report /m,j,w/ and glottal stops vs. typical /d,t,p,b/.

-Limited vocabulary

-Less parent interaction leads to less opportunities

Classifications of cleft palate speech errors

obligatory and compensatory

Obligatory errors

-These are errors that are a direct consequence of anatomic or physiological defect.

-These will spontaneously correct when the cause of the error is corrected. They will be consistently in error until then!

-They include:

-nasal emission - passive escape of air into nasal cavity and out of nose. Can be silent or audible, during consonants

-hypernasality - passive escape of air out nose during vowels

-nasal turbulence, snort

-weak consonantsturbulence -- produced when there is insufficient intraoral air pressure to create the sound.

-Distortions

Compensatory errors

- Not Useful = Compensatory Errors

- Things that a speaker does to replace sounds when they are unable to physically produce actual sound.

- These errors may not be corrected when structural problem is corrected

Compensatory errors with cleft palate

- Glottal stops

- Nasal snorts

- Pharyngeal fricatives

- Pharyngeal stops

- Mid-dorsum palatal stops

These errors significantly impair speech

intelligibility!

Comprehensive assessment

-You may hear "cleft palate speech" infrequently.

-But when you get this child on your caseload you need to be prepared to assess and diagnosis.

****Don't want to misdiagnose.

Always include a diagnostic interview first! What should you include/ask in it?

-Collect a comprehensive history - parent

interview

-Biggest concern?

-Artic?

-Resonance?

-Language?

-Ear infections?

-What kind of speech therapy have they had?

-Progress?

3 ways to assess cleft palate speech

1. Perceptual assessment

2. Intra-oral assessment - oral periph

3. Instrumental assessment- you are not going be doing this in school or home, will have to refer for this.

- Not a comprehensive assessment unless

you have considered all 3 pieces

Why perceptual?

-Some say it is the best predictor.

-Can do it anywhere

-Not invasive

-Can hear both - articulation and resonance

Protocol for perceptual assessment

1. Obtain an adequate speech sample

2. Analyze speech sample

3. Correlate perceptual data with orofacial exam findings

4. Interpret the clinical data

Speech sample - connected speech

Connected speech-

Best representation to:

1. Judge speech intelligibility

2. Error consistency

3. Judge voice quality and resonance

Speech sample if no conversation

- General special sampling contexts - (there is no standard

speech protocol used for Cleft Palate assessment)

- Reading - Zoo passage - no nasals *** see Zoo passage -

- Single syllable repetition

- Repeated syllable productions

- Serial counting - 50-60, 60-70, etc

- High vowel - /u/, /i/

- Words (moon name, long, hand, ring)

- Sentences with nasal consonants

- ABC's, DOW, nursery rhymes, singing

Speech sample - specific testing for hypernasality

- Sample should contain voiced, oral sounds (vowels)

- Prolong "ah"

- Repeating oral syllables: papapa, pipipi, tatata, tititi, kakaka, kikiki, sasasa, sisisi

- See Scape, listening tube, fogging on mirror

Speech sample - specific testing for Nasal Emission

- Voiceless, pressure sensitive consonants (lots of /s/'s)

- Counting 60-70

- 60 or 66 over and over (great combo of plosives and fricatives

- Sustain /s/

- Look for grimacing

- See scape, listening tube, fogging on mirror

Speech sample - specific testing for hypo, denasality, cul-de-sac

- Sample should have high frequency of nasal phonemes

- Counting from 90-100

- 99 over and over

- Mamama, mimimi, nanana, ninini

- Moon, name, long, hand, ring

Analyzing resonance

Ask yourself......

- Did I hear nasality in connected speech?

- Is the nasality intermittent or continuous?

Intermittent = can get some closure or affected by "nearby" nasal consonants.

Continuous = suggests physical VP problem

- Is there a resonance shift between nares-closed & nares-open vowel productions?

- Will have to physically close nares on productions

- "get your wings on"

- What is the overall severity of nasality?

- Global based on connected speech. 0-WNL, 1-mild, 2 moderate, 3-severe

Formal articulation testing

Articulation tests and stimulability testing

Articulation tests

- Iowa Pressure Articulation Test (IPAT)

- Can use Goldman-Fristoe, Kahn-Lewis

- Structured Photographic Artic Test (SPAT-D)

Stimulability testing

Can they do a sound at all even if not consistent? This will determine where to start as well as prognostic information

Analyzing articulation

Ask yourself......

- Did I hear omissions, substitutions, distortions?

- What about placement?

- Are the errors consistent or inconsistent?

- Is there a trend? Developmental errors?

- What do the errors look like? Can I see them?

- Can they imitate?

- What is intelligibility

Weak Pressure Consonants

- Do I hear high pressure consonants?

- Is there reduced loudness?

- Suggests physically based velopharyngeal dysfunction

- Cannot build up intraoral air pressure

Specific testing of CMAs

- Use imitation

- Look for visually noticeable neck activity that is exaggerated.

- Listen for quick voice onset that will suggest glottal stop (*tip-glottal stops are quick voice onset, omissions are smooth).

- Can feel glottal stop.

Analyzing CMAs

- Are CMA's present?

- What types?

- How are they used? Substitutions, co- productions, or both

Other areas to assess

- Developmental errors

- Phonological errors

- Receptive and expressive errors

What should you ALWAYS do?

Always look inside their mouth!!!!!!

Oral peripheral exam

assessment of the structures used to produce voicing and speech

- Speech diagnostic is not complete without an oral facial exam of structures.

- Visual of the structures

- Looking at function

- Can be intimidating and uncomfortable for both

Lips

Structure: Lips

Function: Symmetry and coordinated movement

Tongue

Structure: Tongue

Function: Rate of movement, ROM, precision of placement, isolation from jaw

Palate

Structure: Palate

Function: Indicators of SMC

Velum

Structure: Velum

Function: Does velum raise and elongate

Uvula

Structure: Uvula

Function: Symmetry/bifid

Jaw

Structure: Jaw

Function: Isolation of tongue and jaw, jaw can lateralize in isolation form head

Example protocols

Examining for congenital palatal

insufficiency

-See sample sentences