Kerry Callahan Mandulak, PhD, CCC-SLP

Department of Speech and Hearing Sciences

Portland State University, Portland, OR

Adriane Baylis, PhD, CCC-SLP

Nationwide Children’s Hospital, Columbus, OH

Anna Thurmes, PhD, CCC-SLP

University of Minnesota, Minneapolis, MN

Special Interest Group 5 Short Course

November 19, 2011
 Orofacial Clefting (cleft lip and palate) are
the most PREVALENT birth defects in the
United States
 1 in 600 Caucasian births
 Higher in American Indian / Asian populations
 Lower in African American population

 Affects approximately 6800 babies / year

http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5451a2.htm
Percentage requiring speech-language
treatment
• 50%-75%, from various sources

Percentage requiring treatment for

resonance disorder
• 25%-38%, from various sources

Percentage with middle ear

disease/conductive hearing loss in infancy
• 95%-97%, from various sources
 Multifactorial
Inheritance
 Combination of genetic
and environmental
factors
 Specific genetic regions
have been investigated
 Isolated or associated
with no recognized
syndrome
 Over 350 recognized “cleft
syndromes”
 Only 2 – 4% of total cases
 Specific cleft syndromes
 (Pierre) Robin Sequence
 Apert Syndrome
 Crouzon Syndrome
 Treacher Collins
Syndrome
 Hemifacial Microsomia
 Stickler Syndrome
 22q11.2 deletion
syndrome
(Velocardiofacial
Syndrome)
 Number of SLPs who are members of ACPA:
387 (2006)

Number of SLPs who are members of ASHA Division 5, Speech Science and Orofacial
Disorders:
615 (2007)

Number of SLPs who are ASHA members:

122,762 (2006)

Percentage of SLPs reporting they feel "not competent" to treat children with cleft
lip/palate (Bedwinek et. al, 2010):

44.1%
 Cleft team SLP / Community SLP
• Evaluation vs. treatment

 Scope of practice for SLP =

 Decreased preparation of SLPs to provide

services for children with repaired cleft
palate
 Fewer programs
offering courses

Less courses Small number of

offered training programs

Less academics Less preparation

trained to teach for student
courses clinicians

Fewer places for

doctoral students
Cleft Lip Only • Varies from a unilateral or bilateral notch of
the lip (incomplete cleft) to a complete cleft
(CL) extending back to the incisive foramen

Cleft Palate Only • varies from a unilateral or bilateral cleft of

(CPO) the hard and/or soft palate

• May be unilateral or bilateral

Cleft Lip & • Complete bilateral clefts of the lip result in a
Palate (CLP) “free-floating” premaxilla which is not attached
to anything except the columella (Bzoch, 1997)
 Combination of CLP is more common than CL only or CP
only
 CL +/- CP
 CP only (isolated CP)

 Clefts of PRIMARY PALATE

 Anterior to incisive foramen (lip, alveolar ridge)

 Clefts of SECONDARY PALATE

 Posterior to incisive foramen (hard palate, soft palate,
uvula)

 Complete vs. Incomplete

 Bifid Uvula
 Zona Pellucida (midline tissue of the soft
palate has a thin and/or bluish appearance)
 Bony notch of the posterior hard palate
(need to palpate to feel, cannot be seen)
 “Tenting” of palate on production of “ah”
 May or may not have accompanying
hypernasal speech or nasal air emission
(Peterson-Falzone et al., 2001)
 “Patients with
should be and
their palates repaired if there is
evidence of or
”
(ACPA, 2000)
 The VP mechanism does not merely close for oral
speech and then fall open for nasal consonants or
silence.

 It closes to different degrees, depending on such

variables as vowel height, voicing, and proximity
to nasal consonants.

 Variables: age, gender, phonemic context

“Children who have craniofacial anomalies are
at for speech-language disorders.
Evaluation of speech and language
development provides information that is
needed by the team in
, particularly surgical and dental
management. Further, information about the
patient’s speech and language is important in
the
.”
 Children with an isolated cleft lip are
unlikely to develop abnormal speech
patterns related to the cleft

 Approximately 20% of children with

repaired cleft palate will develop speech
deficits that require additional
intervention (Witt & D’Antonio, 1993)
Communication
• In a child with a cleft…beginning with
development an impaired mechanism
begins at birth.

Controversy
• 9 months vs. 12 months vs. 18 months
over time of • Speech vs. growth
palate surgery…

Heterogeneous
• Errors– cleft related? Or not?
population?
 Problem
 Oral and nasal cavities open to each other

 Lack of place of articulation

 Fluctuating hearing secondary to chronic

otitis media / eustachian tube dysfunction
due to faulty insertion of palatal muscles
(Hardin-
Jones, 2007)
 Cannot create intra-oral air pressure for
sounds like / p b t d k g/
 Phonemic repertoire limited to /m/, /n/, “ng” and
vowels

 Faulty learning for oral air flow sounds

 Affects “manner” of articulation

 Major “place” of articulation missing
 67% of English consonants use alveolar /
palatal structures

 Selective avoidance of consonants that

require hard palate contact
 Research has shown that children with
clefts prefer to make sounds in the
“extremes” of the vocal tract
(O’Gara & Logemann, 1988)
 • Palate and pharynx not working together
VP Dysfunction “properly” for speech production

• Inability of the velum to close off the

VP Inadequacy nasopharynx for the production of oral
consonants

• Structural deficiency: Submucous cleft, short

VP Insufficiency palate/deep pharynx, atrophied adenoids, post-
adenoidectomy, etc.

VP • Neurogenic etiology such as cerebral

Incompetency palsy, TBI, apraxia, etc.
(Peterson-Falzone, 2001)
 Types of resonance disorders
 Hypernasality
 Hyponasality
 Cul-de-sac Resonance
 Mixed resonance disorder

 Nasal Air Emission

 Resonance Disorder ≠ Voice Disorder

 Excessive nasal resonance during speech
production

 Perceptual descriptor (wide range of “normal”)

 Primarily affects vowels and voiced consonants

 Related to inability to maintain separation of oral

and nasal cavities during speech (VPI, fistula,
unrepaired cleft)
 Transpalatal nasalance
 Reduction in normal nasal resonance
 Insufficient nasal airflow
 Primarily affects nasal phonemes (/m/, /n/,
”ng”)
 Indicative of obstruction in nasopharynx or
nasal cavity
 Considered , not resonance
disorder
 Often co-exists w/ hypernasality
 Can be
 Turbulence / patterns of airflow / size of gap
 Can be
 Learned pattern (not due to structural deficit)
 Normal resonance
 Treated w/ traditional articulation therapy
techniques (Peterson – Falzone et al., 2006; Peterson-Falzone & Graham, 1990)
 Type of hyponasality

 Caused by an anterior nasal obstruction

 sound gets “trapped” in nasopharynx

 “Muffled” speech quality

 Defining resonance is not always clear-cut!

 The same child can display both hypernasal and

hyponasal resonance depending on context

 Fairly common in cleft population, especially

post-pharyngeal flap
 • Resonance alteration of vowels and vocalic consonants
Hypernasality that occurs when the oral and nasal cavities are
abnormally coupled
• Reduction in nasal resonance that is heard when the
Hyponasality nasal airway itself is partially blocked or the entrance to
the nasal passages is partially occluded (Peterson – Falzone et.
al 2001)
• Elements of both hypo- and hypernasality which co-
Mixed occur in patients with VPI
• For example, nasal emission heard on high pressure
Nasality consonants (s/z), but nasal sounds are hyponasal due to
some type of nasal obstruction or septal deviation
Cul-de-sac • “Muffled” characteristic
• Tight anterior nasal constriction
Resonance
Nasal Air • Articulation distortion that affects high pressure
Emission consonants (Peterson – Falzone et. al 2001)
 Undiagnosed submucous cleft

 Palatopharyngeal disproportion (congenitally short

palate and/or deep pharynx; ablative surgery to palate
and/or pharynx; excessive tissue removal during T & A)

 Anatomical irregularities involving tonsils, adenoids

and/or faucial pillars

 Limited movement patterns due to neurologic

involvement (Peterson-Falzone, 2001)
 Glottal Stops
 Pharyngeal Stops
 Pharyngeal Fricatives
 Pharyngeal Affricates
 Mid-Dorsum Palatal Stops
 Velar Fricatives (backed oral productions)
 Posterior Nasal Fricatives
 Anterior Nasal Fricatives (grimacing) (Riski, 1994)
 Also considered “obligatory” (equipment)
 Errors Due to Malocclusion
 Class III (“Underbite” or anterior crossbite)
 May affect tongue placement for /t/, /d/, /s/, /z/
and labiodental placement for /f/, /v/

 Class II (“Overbite”)
 May affect lip closure for bilabials
 Sibilants may be distorted
 Crossbite
 Can contribute to lateralization of sibilants

 Lowered palatal vault

 Restricts tongue’s articulatory space

 Dental Deviations
 Missing teeth may result in lateralization of
sibilants
 Rotated teeth may result in distorted sibilants
Kummer, 2001)
Kummer, 2001)
Kummer, 2001)
 Hypernasality, nasal air emission, weakened oral
pressure consonants and/or “structural” errors
 Obligatory or unavoidable errors (probably require
physical management)
 Secondary surgery / Orthodontic / Orthognathic
management

 Compensatory articulation errors

 Learned errors (can remain after physical management;
require speech therapy)
 Classification and description of communication
disorders (Metz, Schiavetti, & Sacco, 1990; Southwood & Weismer, 1993; Eadie and
Doyle, 2002)

 “Gold standard” for clinical speech assessment of

persons with cleft palate (Kuehn and Moller, 2000)

 Provide standards against which instrumental

measures are evaluated (Kent, 1996)

 Treatment should only be indicated when a problem

is perceived by a listener (Moller, 1991; Conley et al., 1997)
 Types of Rating Tasks
 Categorical
 Mild-moderate-severe
 Equal-Appearing Interval Scaling
 0-6 rating scale
 Direct Magnitude Estimation
 Rate the magnitude or ratio of difference
between stimuli
 Other: Visual Analog Scaling, Binary, etc.
 Intelligibility

 Articulation
 Nasal air emission

 Resonance

 Voice

 Acceptability
 Methods of assessment
 Categorical
 Rating scales
 Percentages
 Comparison to peers
 Listener: familiar
vs unfamiliar
 Context: conversation vs predictable
tasks
 Listen for:

 compensatory articulation errors

 audible nasal emission

 “weak” oral pressure consonants

 other articulation and phonological errors

 Listen and watch for:

 Anterior Crossbite (Class III malocclusion)

 Distortions: fricatives, affricates, sibilants
 Labiodentals: reversed labiodental placement
 Overjet (Class II malocclusion)
 Bilabials: labiodental placement
 Missing / malopositioned teeth
 Distortions of sibilants
 Listen for:
 Reduction or elimination the plosive quality of oral
stop consonants or fricatives (high pressure
consonants p, b, t, d, k, g, f, s, sh, z, ch, dg, th)
 Pressure improves when you plug the nose

 Often co-occur with audible nasal emission

 When severe, oral stop consonants can be

perceived as nasal consonants (bm)
 Listen for:
 (includes nasal turbulence, nasal snort, and nasal rustle)

 Obligatory: consistent nasal emission on

virtually all pressure consonants
 usually accompanied by hypernasality
 Usually present on all pressure consonants
except VELARS if due to a fistula only
VS.
 Learned: only heard on specific sounds such as
/s/, /z/, /ʃ/, /ʧ/, and/ or /f/
 Watch for nasal/facial grimacing
 Typically used as substitutions for /s/, /z/,
/ʃ/, /ʧ/, /f/
 Phoneme-specific nasal emission

 Diagnostic approaches to differentiate

nasal fricatives vs. obligatory audible
nasal emission
 Nasal occlusion
 usually associated with
VPD
 PERCEPTION of excessive nasality (too much
nasal resonance) during production of vowels (esp.
/i/, /u/), glides (/w/, /j/), and liquids (/l/, /r/)
 Often co-occurs with audible nasal emission
(although inverse relationship with gap size and
“turbulence” of nasal emission)
 Often co-occurs with weak pressure consonants
and/or nasalized oral consonants
  usually associated with
nasal obstruction, obstructive pharyngeal flap,
midface hypoplasia, septal deviation, choanal
atresia, adenoid hypertrophy
 PERCEPTION of denasality/too little nasal
resonance during production of vowels and nasal
consonants /n, m/ and “ng”
 Denasalized nasal consonants, makes them
perceptually similar to their oral counterpart
(/m//b/, /n//d/)
 Resonance distortions can vary in or

 Hypernasality may be inconsistent in presence or

severity
 Hyponasality tends to be consistent in both
respects
 Mixed distortions tend to be the most variable

 If articulation skills are severely impaired, may make

it very difficult to judge resonance
 E.g., child with pervasive glottal stops
 Listen for:
 often associated with VPD or pervasive glottal stop errors
 Characteristics: rough, breathy, strained, decreased
loudness
 Possible vocal nodules

 Volume/intensity
 Is reduced loudness or dysphonia masking the severity
of hypernasality?
 VPD may result in the perception of reduced loudness
 Is increased loudness/effort being utilized to increase
pressure to compensate for VPD?
 To the patient? Family? Clinician? Surgeon?

 Based on input of one or all?

 Impact on future vocational choices?

 Obtain an adequate speech sample
 Perceptually analyze each speech parameter

 Correlate perceptual speech data with any

orofacial examination findings
 Interpret your observations

 Make impressions/diagnosis
 Recommend instrumental assessment and
imaging if concerns with VPD
 Target your listening to different portions of
the speech sample and RECORD the speech
sample so you can listen again later
 Intelligibility: conversational sample (include
some low-predictability questions)
 Articulation: use standard sentences and
standardized testing (e.g., GFTA-2)
 Voice, resonance, nasal emission: use
standard sentences, reading passage,
conversational speech
 Depends on age of patient, cognitive
ability, reading ability, attention span

 Conversational sample
 Reading passages
 Picture description task, counting, recite
words to a nursery rhyme, etc.
 Repetition of a standard list of phrases and
sentences (Henningsson et al., 2008; Trost Cardamone et al., 2011)
 Oral-only (no nasal phonemes, usually loaded with
high pressure phonemes)
 Buy baby a bib. Pet the puppy. Take it to Ted. Daddy did it.
Go get a bigger egg. I like cookies. I have six sisters. Shelly
wears shoes. Zebras live at the zoo. Chuck goes to church.
Judges like to jump. Fifty five fish.
 Nasal-loaded
 Mama made lemonade. Ten men came in when Jane rang.
 Mixed (oral and nasal phonemes)
 Listen during:
 Oral-only stimuli (test for VPD symptoms)
 Nasal-loaded stimuli (test for hyponasality)
 Vowels or sustained SSS, FFF

 If a patient has  listen for increase in

pressure, improved resonance, and elimination
of nasal emission when nose is closed.

 If patient is : listen for lack of change

in nasal consonants when nose is closed.
 Nasal emission may or may not be audible…
 Listen for presence, consistency, and quality
(turbulence) of nasal emission
 Determine if phoneme-specific or not
 Determine if only related to a fistula or not

 Confirm what you hear

 look for fogging during oral
consonants; Fogging immediately prior to and
after sentence production is NORMAL
 Can also use See-Scape, listening tubes, straw
 Various standardized articulation tests are
acceptable for use with patients with cleft
palate/VPD (e.g., GFTA-2)
 Compare to norms
 Older “Cleft Palate Tests” are not widely used
anymore
 Iowa Pressure Articulation Test
 Bzoch Test
 Fisher Logemann
 What CAN the speaker do?
 Stimulability testing with the nose plugged
for oral consonants
 Consider dental-occlusal hazards too
 Are any
related to the articulation errors?
 Dentition: missing/malposed teeth
 Occlusion
 Orthodontic appliances present (e.g.,
expander, W-arch wire)
 Maxillary arch width
 Lips: closure at rest/breathing and speech
 Open mouth posture? Difficulty with lip closure due to
overjet?
 Don’t overanalyze “tension” of upper lip after cleft lip
repair
 Fistula in hard or soft palate
 Soft palate:
 Length: short? Can you see the adenoid pad?
 Elevation during /a/ phonation: hints
 Symmetrical? Degree of elevation?
 Uvula (for noncleft patients): single and at midline?
bifid? Other signs of SMCP?
 Tonsils: size
 Consider:
 Is the child’s speech appropriate for their age?

 Is intelligibility and/or acceptability significantly impacted by the

child’s speech disorder?

 Is the speech profile suggestive of underlying VPD?

 Are there articulation distortions due to dental-occlusal hazards?

 Is the child stimulable for improved articulation?

 What other factors are contributing to the speech disorder (e.g.,

hearing loss, fistula, nasal congestion, learning difficulties, etc.)?
 Is additional diagnostic information necessary?
of VP closure for speech
(e.g., imaging)? Acoustic assessment of nasality (e.g.,
Nasometry)?
 Other medical testing (e.g., audiometry, genetics)?

 Is a necessary
BEFORE performing imaging studies or making
recommendations for physical management of
VP closure for speech?
 Does the instrumental assessment support
the need for behavioral treatment (therapy)
or physical management (surgery or a
prosthesis)?

 What can the instrumental assessment tell

us about the type of intervention that
should be recommended?
 Perceptual speech assessment

 Acoustic (e.g., Nasometry)

 Aerodynamic (e.g., Pressure-flow)

 Visualization of the VP mechanism

 Nasopharyngoscopy
 Multiview Videofluoroscopy
 Acoustic correlate of nasality
 Nasalance = nasal sound energy / nasal + oral sound
energy
 Higher nasalance correlates with perception of
hypernasality
 Not a 1:1 relationship to listener perceptual judgments
of resonance, but should confirm what you hear
 Good tool for comparison pre/post treatment

 Different products on the market can measure nasalance

 Nasometer II (KayPentax), Glottal Enterprises
http://www.kayelemetrics.com/Product%20Info/6400/6400.htm
 Expressed as a percentage (or ratio),
ranges from 1-100% (you can’t have 0%
nasalance)

 Norms available for a variety of stimuli,

languages, dialects
 Various stimuli options
 Standard reading passages
 Zoo Passage
 Rainbow Passage
 Nasal Sentences

 SNAP test-R (Simplified Nasometric Assessment

Protocol, McKay-Kummer)
 Patient repeats syllables and prolonged sounds
or produces sentences using read or picture-
cued stimuli
 Treatment applications
 Biofeedback therapy
 Different treatment targets

 Ideal candidate: age 8 years+, good

attention span, cooperative, can read
sentences/passages, stimulable to modify
nasal emission or resonance, good
articulation, motivated
 The Nasometer does not measure hypernasality
 The Nasometer does not measure nasal airflow

 Multiple score confounds lead to risk for

underestimation or overestimation of nasalance
score:
 Articulation errors, nasal congestion, nasal
turbulence, voice disorders, mixed resonance,
dialect/accent

 Surgical decisions should not be based only on

nasalance scores
 Often called “multiview videofluoroscopy”
 Lateral view, frontal view, base view, Towne’s view

 Exposure to radiation

 Usually involves administration of barium via the

nasal cavity

 Assess VP closure for speech, palatal length and

elevation, size of adenoids and tonsils
 Patient repeats words and phrases
 Provides direct view of VP (and laryngeal) structures
and the VP port during speech

 Flexible fiberoptic or CHIP TIP technology combined

with a nasopharyngoscope (adult or pediatric sizes)

 Topical anesthetic and nasal decongestant typically

used

 Higher cooperation required

 Patient repeats standard words and phrases (primarily

oral-only sample used to assess VP closure)
 Determine presence and extent of VPD
during speech
 Size of gap, shape
 Consistency of VP closure
 Movement of individual structures (velum, LPW,
PPW)
 Size of adenoids, tonsils, and potential role in VPC
 Signs of occult SMCP
 Limitations of Nasopharyngoscopy
 Subjective—cannot obtain absolute
measurements of gap size
 Differences in viewing perspectives,
position of scope
 Possible tongue backing contribution to
VPC
 Minimally invasive
 Discomfort
 Cooperation best if age 4 yrs+
 Biofeedback therapy with
Nasopharyngoscopy
 Option for treatment of compensatory
errors (e.g., glottal stops, nasal fricatives)
 Provide visual cues for closure on specific
sounds
 Compare and contrast open/closed port
 Requires highly cooperative patient,
typically older schoolage, teen, or adult
 Readily intelligible speech

 Socially acceptable speech

 Age-appropriate articulation skills

 Age-appropriate language skills

 Improve velopharyngeal
closure as soon as it is clear
that the potential for
adequacy is not present

 Most surgery for VPD is

between 3-6 years
1. Improve VPC (physical management) but no
speech therapy needed

2. Improve VPC and speech therapy needed

3. Speech therapy only- defer decision on VP

management until additional therapy completed

4. Speech therapy needed and VPC is adequate

5. No treatment needed (continue to monitor)

 Start therapy as soon as possible- for
surgery or the cleft team to tell you to start
therapy
 Need to establish at least some correct articulation
placement prior to VP imaging or surgical decision

 Utilize a hierarchical- traditional articulation

approach that

(minimum
2x/week) on an especially when
compensatory articulation errors are present
 Only one sound is targeted and
stabilized at a time in a hierarchical
progression of speech contexts

 Start with isolation, syllable level,

words, multisyllabic words, phrases,
sentences, then connected speech

 Make sure that the child can produce

the sound in spontaneous/connected
speech before moving to the next goal.

 Give the child sufficient practice to

solidify the “new sound” aim for high
accuracy (90%+)
 Where do I start?
Options:
 Start with the sounds causing the most negative impact on
intelligibility or VPC (the compensatory errors)

 Target sounds for which the child is stimulable

 Keep developmental progression in mind, but don’t be

afraid to deviate from it

 Start with the sounds that are most visible (anterior)

 Usually, it is easier to start with voiceless sounds before

voiced ones (especially if glottal stops are present)
 Articulation errors
 compensatory articulation errors
 placement errors (substitutions, distortions)
 omissions
 backing of phonemes and other phonological errors

 In carefully selected cases, inconsistent mild

hypernasality or inconsistent audible nasal emission
MAY be improved with behavioral therapy
 Usually with biofeedback refer to a cleft SLP
expert for this treatment
 Traditional Articulation Therapy is the
preferred method of treatment
 In most cases, this is NOT phonological therapy, at least not
initially

 NOT oral-motor therapy

 This is therapy focused on phonetic-based approaches,

with perceptual training using auditory, tactile, and visual
cueing, and self-monitoring techniques
 Also utilizes motor-learning principles
 Drill practice as soon as child is mature enough
 Teach identity, location, and actions of
oral structures
 Teeth, lips, tongue
 Use a picture, mirror, Mr. Potato, Mighty-Mouth
 Teach sounds and their corresponding structures
 /p/: lip sound, popping sound, poof sound
 /t/: tongue sound or teeth sound
 /s/: snake sound
 /ʃ/: quiet/windy sound
 Get the target sounds into the inventory
 Use easier sounds to elicit new sounds (shaping)
 /w/ or /m/ /p/, /b/
 /l/ or /n/  /d/
 /j/  /ʃ/
 Provide auditory, visual, and tactile cues
 Use nasal occlusion as needed
 Teach correct oral target vs error sound contrasts
 auditory discrimination & negative practice: “old sound” vs
“new sound”
 Establish reliable self-monitoring
 Teach them to discriminate and identify “throat”
sounds vs “mouth” sounds (or “nose” vs “mouth”)
 Start teaching most visible or anterior sounds (e.g.,
/w/, /h/, /p/, /t/) and shape into target sounds
 Try voiceless sounds first (e.g., /p/, /t/ before /b/, /d/)
 Plug nose as needed to provide sensation of oral
pressure
 Try /h/ words with the final consonants as targets
(e.g., hoop, hop)
 Use overaspiration of air and whispering as needed
 Avoid words with nasal sounds or vowel initial words
 horn-therapy program

 straw blowing/lip strengthening program

 palate massage/stimulation program

 yawning/sighing exercises

 whistle blowing exercises

 tongue movement exercises

 “cookbooks” to improve resonance

 See-Scape
 Sometimes useful for treating learned nasal
emission (nasal fricative substitutions)—only if
Phoneme Specific
 Auditory Biofeedback: listening tube,
straw, oral-nasal listener
 Nasopharyngoscopy
 Nasometry
 ? CPaP (Kuehn 1991, Kuehn et al., 2002)
 Surgical
 Palatal lengthening and muscle repair
(Furlow Z-plasty)
 Superiorly-based pharyngeal flap
 Sphincter pharyngoplasty
 Posterior wall augmentation / Fat injections

 Prosthetic
 Palatal lift
 Speech bulb
 Indicated for short
soft palate (or
minimal elevation)
when at least
some degree of
LPW movement is
present
Pharyngeal
Flap
 Indicated when soft
palate length and
elevation are
adequate but there
is minimal LPW
movement

http://www.drlandis.com/pro/clsurg.htm
 Furlow z-plasty
 Muscle reorientation/repair and lengthening
 Often used for SMCP repair
 Option for very small VP gaps, nonsyndromic
cases

 Pharyngeal wall augmentation (rarely

used)
 Fat injection: results may only be temporary
When most commonly considered:
 Multiple surgical failures

 Surgical risk

 Airway concerns

 Neuromuscular etiology of VPD

 Borderline cases

 Diagnostic treatment
 Palatal Lift Speech Bulb
Obturator

KNC/AT/LG/KM '10
 Palatal Bulb
Palatal Lift

KNC/AT/LG/KM '10
 5 year old female, adopted from China

 Repaired bilateral cleft lip and palate (lip-China, palate-age 2

years in US)

 Chronic OME, unilateral conductive hearing loss at last visit with

right ear perforation

 In therapy at a local private practice, 1x per week, targets

include /p/, /t/, and blowing exercises

 Unable to enroll in school-based therapy

 Held back from kindergarten this year due to concerns with

intelligibility
 Perceptual Speech Evaluation
 Standardized Articulation Testing
 (Language Testing)
 Oral Exam
 Articulation errors:
 Pharyngeal fricatives for S, F, SH, Z, CH, TH, J
 Glottal stops for T, P, K, SH, Z, G, and inconsistent glottal
coarticulation
 Nasal substitutions for K, G, Z, F, TH, CH, B, V
inconsistently
 W/R substitutions
 D/G substitutions inconsistently
 B/V substitutions
 H substitutions for S, Z inconsistently
 Consistent weak pressure consonants
 Standard Score: <40, Percentile Rank <1st
 Intelligibility : Child's connected speech is usually
intelligible to familiar listeners but only
occasionally intelligible to unfamiliar listeners
 Hypernasality: severe
 Hyponasality: none
 Audible Nasal Emission: present
 Voice Quality: rough, breathy
 Articulation: compensatory errors present
 Dentition: Anterior crossbite (underbite)

 Fistula: Anterior hard palate fistula

 Palate: Soft palate is judged to be short in

length

 Passavant's ridge activity is visible intraorally

 Is there a role for continued or increased speech
therapy?
 What suggestions would you make to her current
therapy programming?
 Would instrumental assessment of nasality be
helpful (i.e., Nasometry)?
 Is VP imaging indicated now?
 If yes, what stimuli would you use?
 What is your tentative hypothesis for the
etiology of her speech disorder?
 Increase frequency/intensity of current speech-
language services to at least 2-3x per week with
primary focus on articulation placement skills

 Therapy should target remediation of glottal

stops, nasal substitutions, and pharyngeal
fricatives first, before moving to other goals.
 Provide extensive placement cues for target sounds.

 Discontinue use of blowing exercises.

 Carryover of accuracy at the word, phrase,
sentence, and spontaneous speech levels at 90%
accuracy for each target, prior to adding new
goals to ensure mastery of skills.

 Nasal occlusion may be helpful (nose plugging) if

tolerated intermittently during therapy.

 Avoid excessive loudness/effort during therapy

sessions to minimize vocal hyperfunction.
 Nasometry was not completed due to
frequency and type of articulation errors
and dysphonia, as well as some
cooperation challenges
 Cooperation was poor
 Level of speech sample: Single syllables and words
only (sample focused on accurate phonemes only)
 Consistent velopharyngeal gap present during an
oral-only speech sample.

 VP Gap Size: 4-Large

 Location of VP gap: Central
 VP Closure Pattern: Coronal
 Degree of Palatal Elevation: Minimal
 Medial Movement of the Lateral Pharyngeal Walls:
Minimal
 Would you proceed with recommending
physical management?
 If yes, surgical or prosthetic?
 Pharyngeal flap

 Increased speech therapy

 Future fistula closure/obturation

 Management of hearing loss

 Reassess speech at Team visit 6 months

post-surgery
 12 year old male
 22q11.2 deletion syndrome (velocardiofacial
syndrome)
 Congenital velopharyngeal dysfunction
 S/P pharyngeal flap, flap revision, previous
tonsillectomy and adenoidectomy

 Seasonal allergies, learning disabilities, social skills

deficits
 Home schooled, receiving “teletherapy” for
articulation and language
 Parent voices concerns with resonance and
intelligibility
 Perceptual Speech Evaluation
 Standardized Articulation Testing
 (Language Testing)
 Oral Exam
 Nasopharyngoscopy and Nasometry
 Intelligibility: intelligible to familiar listeners
consistently, occasionally not understood by
unfamiliar listeners
 Hypernasality: moderate
 Hyponasality: none
 Audible Nasal Emission: Consistently inaudible,
inconsistently audible
 Voice Quality: rough
 Articulation: compensatory errors present, weak
pressure for consonants
 ? Dysarthric features
 Standard score: 40, Percentile Rank: <1st
 Errors:
 glottal stop substitutions for K and G,
 nasal fricatives for F and V,
 N for NG,
 N for L inconsistently,
 nasal fricative inconsistently for "J",
 nasal fricatives for TH,
 H/K substitutions only in blends.
 W/R substitutions
 distortions of CH
 S/SH substitutions
 Articulation errors were noted to increase with an increase in
utterance length and complexity. This includes a significant
increase in frequency of glottal stop errors in conversation as
compared to structured tasks.
 Facial and lip asymmetry at rest and in motion
 The left side of his face/lips has reduced movement
 Facial/lip motion for smiling is reduced.
 Significant overjet which interferes with lip
closure
 Soft palate demonstrates asymmetrical
elevation toward the right side
 Suggests left palatal weakness.
 Sensitive gag reflex observed
 Unlikely to tolerate palatal prosthesis
 Zoo passage: 46% (mean 15%, +/- 5%)

 SNAP stimuli (picture-cued subtest):

 Bilabials: 20% (mean 11%, S.D. +/- 5%)
 Alveolars 27% (mean 11%, S.D., +/- 5%)
 Very cooperative for the procedure.
 Slightly narrow and asymmetrical pharyngeal
flap is present.
 The left port is larger than the right at rest.
 The right port demonstrates virtually complete
(.90) closure during most speech tasks, with
some mucous/bubbling.
 The left port demonstrates an inconsistent
degree of closure, based on the speech stimuli
and accuracy.
 For accurate oral phonemes, closure is estimated at
.80-.90, but during inaccurate speech, closure is
approximately .20 on the left
 Demonstrated the ability to modify and increase the
closure of the left port during speech with
endoscopic biofeedback
 L lateral pharyngeal wall demonstrates reduced
degree of closure and slower motion than R side
 Consistent with suspected left pharyngeal weakness
 Atypical posterior pharyngeal wall motion
emanating near midline with extension toward the
left side of the pharynx is noted during speech
 Likely a compensatory behavior to assist with VP closure.
 COMBINATION of traditional and biofeedback
 2x per week
 TREATMENT GOALS:
 Increased VP closure for speech (left VP port)
 Accurate articulation placement
 Additional formal language testing.
 Candidate for flap revision in future
 Depends on results of therapy
 Re-eval with Cleft/Cranio team in 6 months
 Orthodontic treatment to correct his overjet to
facilitate lip closure.
 TRADITIONAL:
 Placement for velars
 Placement / oral airflow for /ʃ/, /ʧ/, /ɵ/, /f/, /j/
 NASOPHARYNGOSCOPY:
 100% closure in 80% of words and phrases targeted.
 NASOMETRY:
 Nasalance scores within normal limits at phrase level
for SNAP stimuli
 80% accuracy (below target reference line) for specific
target words and phrases
 Consistent home practice
 Achieved stimulability for velars with slight
distortion, with higher accuracy for /k/ than /g/
 CURRENT STATUS:
 /k/ in all positions of words (with slight distortion) with
a model and intermittent auditory cues in 90% of
opportunities
 /g/ in isolation with 75% accuracy (inconsistent
uvularized placement or glottals)
 /ʃ/, /ʧ/, /f/ and /ɵ/ in words and phrases reviewed and
75% accuracy noted with frequent placement and
auditory cues needed
 Can produce all vowels except /i/ at or below a
40% nasalance reference line with and without a
model;
 CV syllables for /p/, /t/, /k/, /s/, /ʃ/ with a model for
all vowels except /i/ with 90% accuracy
 Can produce these CV syllables in oral-nasal
contrasts with 90% accuracy
 Can produce CVC words for this set of sounds
below the 40% reference line for all vowels
except /i/ with 75% accuracy
 Articulation placement for /k/ at the word and
short phrase level.
 Achieved 90% accuracy in words and 80% in phrases
(in all word positions) with a model, with slight
distortion persisting inconsistently.
 /g/ is produced with uvular placement or as a /k/
substitution
 Fricatives and affricates:
 90% accurate for oral airflow (with S/SH placement
issues) at the phrase level
 Decreased accuracy noted in spontaneous speech--but
good self correction with minimal cues
 No change in resonance in spontaneous speech.
 Ccontinued difficulties with /i/ and /u/
 Anticipatory nasal emission noted for /t/ and /d/
but generally oral and accurate
 /p/, /b/, /k/ and fricatives accurate at the syllable
and selected word level
 Goals sustained at 30% reference line in 80% of
cases at the syllable level only for constrained
stimuli (without /i/, /g/, /u/ and diphthongs)
 5:10 year old male
 Adopted from China

 Lip repair: China (age 7 months)

 Palate Repair: Age 15 months

 Fistula Repair: Age 2 years

 Secondary Surgery: Palatal lengthening at

4:9
 Highly compliant for nasopharyngoscopy
 Received speech therapy through EI and
privately (outpatient)

 Had attended speech therapy at PSU, 2x

weekly, in Spring 2011 term

 Enrolled in 2011 Summer Clinic program

at PSU
 CONCERN: speech intelligibility
 Receptive / Expressive Language:
 Not formally assessed, but believed to be well above-
average
 Reads at 2nd grade level (at age 5)
 Speech:
 Distorted /s/ and /ʃ/
 Gliding errors on /r/ and /l/
 Final consonant deletion of plosives and /s/
 Speech intelligibility improved with slower rate and focus
on precision
 Nasal air emission on labial and alveolar sounds
 Resonance:
 WNL
 Large anterior oral-nasal fistula

 Advanced cognitive skills

 Maintenance of speech skills

 Financial / Insurance constraints

 Adequate velopharyngeal closure

 Accurate placement of /s/, /ʃ/, /l/
 ISSUES:
 Loss of airflow, especially at the end of a sentence
 “is,” “was,” “his”
 Equipment issues!
 PROGRESS: Accurate production of /l/ as singleton
(not yet in blends)
 Implementation of self-monitoring skills for
rate
 Slower rate / over articulation
 Visual and verbal cues
 Reading aloud
 Work within constraints

 Promote effective / efficient

communication
 Preserve self-image / self-esteem

 Communicate with parents regarding

expectations
ASHA5shortcourse@gmail.com