Cleft Palate Speech-Part 2: Assessment, Intervention and Medical Referrals Related to the School-Aged child With Cleft Palate Jeff Steffen M.A., CCC-SLP.

Cleft Palate Speech-Part 2:Assessment, Intervention and

Medical Referrals Related to the School-Aged child With Cleft Palate

Jeff Steffen M.A., CCC-SLPManager, Foothills Speech and Language LLC

Children’s Hospital Colorado, Cleft Lip and Palate Team Consultant

www.foothillsspeech.org

Structure Vs. Function

• The Bridge to Nowhere

Typical Surgical Timelines The School Aged Child

• Lip and Nose Revision Age 4-5• P.E. Tubes As needed• Secondary Management Age 4-6• Palate Repair Submucous Age 3-5• Bone Graft Age 8-10• La Fort I, II, III Age 15+• Final rhinoplasty Age 15+

Assessment of Structure and Function

• The head and face• The lip and nose• The Alveolar Ridge/anterior palate• The Mid Palate• The soft Palate

The Head and Face

Structure

• Visual alignment of parts• Use a tongue blade

Function

•Facial and cranial Nerve Tests• Symmetry of smile• Lip strength• Blink eyes• Strength against resistance• Lingual mobility• Palate mobility• Swallow• Gag reflex

The Lip and NoseStructure

• Nasal symmetry• Septal deviation• Turbinate hypertrophy• Columella length• Lip symmetry• Labial frenulum• Lip rounding

Function

• Possible nasal obstruction• De-nasal resonance• Open mouth breathing• Forward tongue placement• Allergies• Interdental distortions• Hard to occlude nose• Poor lip rounding /w/, /r/

The Alveolar RidgeAnterior Palate

Structure• Lateral segment collapse• Fistula (multiple)• Tooth in palate• Dental decay

Function• Airflow distortion• Poor lingual placement• Nasal emission• Mid-dorsal placement• Obligatory errors

– Occlusion Class III

• Aberrant sounds (sucking air through fistula)

Assessing Palatal FistulaDoes it effect velopharyngeal function?

Tools for Assessment

Temporary Obturator

• Make a “Mouth Pancake”• Use bilabial sounds and low pressure sounds• Re-test Nasal Emission• Perceptual changes on vowels– Use listen tube

• Obturate or not? Pros/cons

Surgical Closure of fistulaeConsiderations

• Anterior fistula with bilateral lip/palate• Scaring and effects of future expansion• How symptomatic is it? (explain yourself)• Does size matter?• Tongue flap, etc.

The Mid Palate

Structure• Fistula

– May not be able to obturate

• Arch height• Scaring

Function• Nasal Emission• Mid dorsal stops• Backing errors• Food/liquid in palate• Effect on resonating space

“The Crux of the Biscuit”The Posterior Palate

Structure• Short Palate• Immobile Palate• Incomplete resection of

Levator• Dehiscence• Fistula• Tonsil/adenoid hypertrophy

Function• Velopharyngeal Dysfunction• Velopharyngeal Insufficiency• Velopharyngeal Inadequacy• Velopharyngeal Incompetency• Neurologic component• Velar notching• Snoring/OSA

Assessment

• YOUR EARS!!!!!!!!!!!!!!!• Rating Scales• Nasometry• Nasopharyngoscopy• Videoflouroscopy• Still x-ray of “eeeee”

20% require secondary management

Rating Scales

Speech Scales

Treatment Vs. Medical Management

Compensatory

Mis-articulation

Patterns

Glottal Stops

Pharyngeal Fricatives

VPD

FISTULA

Hearing loss

Nasal Emission

HypernasalsnoringADHD

More therapy

TreatmentThe Speech Sample

Pepperoni PizzaPick up the puppyTake a turtle to lunchDaddy ate the DoughnutsDaddy does the dishesChugga chugga choo chooFind the funny foxGo get cake and cookiesSusy slipped on the ice

Speech SampleLow Pressure Sentences

Hi how are you?Where are you?I love you. I have a yellow yoyo.Oh wow.

Sustained vowels

Who’s Ready to Play?

•Conceptual awareness• The right Timing•Coaching versus Teaching• Inspiring!!!

Conceptual Awareness (For the Player)

Door OpenNose Talking

Door ClosedMouth Talking

Conceptual Awareness(For the Parent)

Eliminating Errors(Glottal Stops)

Start with Voiceless Stop /p/• Whispered (use /h/ transition to vowel)• After “ah”• Puff checks out and press checks for short oral

release of air.• Use listen tube• Lip trill (horse sound)• Use placement map

Or you can try

• Voiced /b/ but not as much tactile feedback• Especially if voicing errors occurring• Use in final position as air is moving already• Repeat final position to approximate medial• Move to whisper of initial vowel sound (uh)

• Once established much like articulation therapy.

Tricks of the Trade

• Use paper “snow” balls, cotton balls – Position of mouth to paper important

• Reverse use of listen tube• Cul-de-sac technique (pinch nose)• Discrimination (auditory/production)– Hand on throat to feel laryngeal elevation

Tricks of the Trade

• Use paper “snow” balls, cotton balls – Position of mouth to paper important

• Reverse use of listen tube• Cul-de-sac technique (pinch nose)• Discrimination (auditory/production)– Hand on throat to feel laryngeal elevation

Pharyngeal Stops

• Teach anterior placement first– Can try the yawn technique (lowers tongue base)

• Velar placement – /g/ often easier from –ng (Inga)– Hold anterior tongue “in bed”• The anti-nap technique for awareness

– Can try tongue blade to hold tongue down– Push tongue back (gagging)– Use mirror and/or video feed back

Pharyngeal Fricatives

• Release /t/ into an /s/ (don’t mention /s/)• Use straw (McD’s or Starbucks)• Determine if other phonemes affected– /f/ (pinch nose)– Bite teeth (often too hard for air flow)– Pretzel sticks or liquorish ropes– Popsicle stick (slants downward)/air over top

• “sh”..hush sound– Occlude nose

– Video clip of visual feedback

The Palatal /s/

• Teach awareness of posterior lateral blades of tongue

• Biting/pressing tongue to maxillary incisors • Straw across teeth at canines• Mouth Space and the pink alien– Mirror– Good for frontal /s/ too

The Palatal /s/

• Teach awareness of posterior lateral blades of tongue

• Biting/pressing tongue to maxillary incisors • Straw across teeth at canines• Mouth Space and the pink alien– Mirror– Good for frontal /s/ too

Phoneme Specific Nasal Emission

• Diagnose it first– Sentence without /s/– Compare to counting 60-70

• Teach awareness and discrimination– Many of the /s/ techniques can be useful

• Use placement map • Praat Software for older kids?

Hypernasal resonance

• Rarely does speech alone help• Teaching correct function/articulation can

improve it.• Over articulation techniques• Slowing rate• Possible motor coordination VP timing issue• Oral/nasal contrast (be more hypernasal)

– Sound clip of congenital VPI– Video clip of oral/nasal contrast

Praat (/s/ nasal fricative)

Praat (ba…mba)

Referring for Medical Management

• Determine if seen by a team• Get most recent report/follow up with rec’s• Refer to SLP for consultation/2nd opinion• Write update as to why management.

Jeff Steffenwww.foothillsspeech.orgjeff@foothillsspeech

Question self and others

Inspire !!!

Thank you (and enjoy)