Speechtherapy- cheilopalatoschizis

The Role of the Speech and Language Therapist in the Cleft

Team

Sue MildinhallLead Speech and Language Therapist

South Thames Cleft ServiceGuy’s and St Thomas’ NHS Trust, London, England

South Thames Cleft Clinics

Outcomes of cleft palate surgery

Speech

Appearance & Growth

Psychological well-being

Plan

1.To describe the work of the Speech and Language Therapist in the cleft team

2.To discuss speech difficulties associated with cleft palate

3. To describe how we manage the speech problems of the child with cleft palate

Aim of the Team

To ensure best possible speech outcome for child born with cleft palate as early in life as possible

The work of the Speech and Language Therapist (SLT)

• Monitor speech development and speech outcomes in relation to cleft

• Provide differential diagnosis for cleft/non cleft speech problems

• Advise surgeon when VPI suspected & about all slt issues

• Participate in multi-disciplinary clinic• Speech assessments & palate investigations• Teaching • Liaise with local SLT or family about treatment

strategies• Provide therapy to local or challenging cases

How do we do this?

• Early speech and language development advice

• Speech assessments at regular intervals

• Therapy as needed

• Regular joint clinics with surgeons

• Regular feedback to surgeons on outcomes

How do we speak ?

• We speak on exhaled air• Voice is produced by the larynx• The soft palate lifts to close off

the nasal cavity• We shape the air with lips &

tongue to make different sounds

• Sequence into words & sentences

Why is the soft palate important?

• Romanian has 20 consonants

• English 24 consonants• Only 2 are nasals – n m• All the others are oral &

are produced with a raised soft palate

• Closure is particularly important for the sounds requiring a build up of oral pressure

key

Types of speech problems

• May sound “nasal”

• Sounds may be mispronounced/omitted

• Nasal consonants (m n ng) should be possible

• Oral consonants (pb td kg s f sh ch) are vulnerable

What might cause the problem?

• Soft Palate may not work effectively

• Fistulae

• Orthodontic problems Malocclusion

• Fluctuating Hearing Loss

What do we assess?

1. Intelligibility – can we understand the child?

2. Airflow problems -balance of air resonating in oral/nasal cavities? Nasal emission of air?

3. Articulation – are sounds produced correctly?

Intelligibility

How difficult is it to understandthe child according to;1. The parent/carer2. School/Nursery3. Unfamiliar adults4. The SLT?

What is the reason for the poor intelligibility?

Airflow Problems –Hypernasal resonance

• Too much air resonates in the nasal cavity

• Oral consonants can sound nasalised

• Or become nasal eg b=m

• Suspected velopharyngeal insufficiency (VPI/VPD)

Airflow Problems - Audible Nasal Emission

• Audible air escape from the nose

• Heard accompanying sounds eg p, t, k, s, f

• ? Fistula or VPI

2. Articulation

Cleft-type speech patterns: (GOS.SPASS 1998)

1. Lateralisation2. Palatalisation3. Backing to velar4. Backing to uvular 5. Pharyngeal 6. Glottal7. Active Nasal Fricatives8. Weak nasalised consonants9. Nasal realisations10. Absent pressure consonants

Who will need speech therapy?

• 50% 5 year olds more or less normal speech

• 81% 12 year olds “ “ (CSAG 1998)

• Prediction of cases impossible

• 25 - 30% will need further surgery for speech (CSAG 1998, Mildinhall et al 2007)

The skill of therapy

• Recognise when children are ready/not for therapy

- What needs therapy and what needs surgery

- Provide therapy in a timely and fun way

- Work with families, giving them the skills to- continue work at home

- Adapt therapy style according to child’s needs

Why investigate?

• Perceptual speech assessment indicates characteristics of VPI

• Objective investigation required to inform further management

• Oral examination alone inadequate• Videofluroscopy shows us the structure.length,

stretch of the soft palate during speech• Nasendoscopy shows sphincter from above

• Leads to treatment plan

Speech Surgery after investigation

• Palate re repair• Pharyngoplasty• Posterior pharyngeal wall implant

• John Boorman• Norma Timoney

Summary

• Speech and Language Therapist’s role in assessment, diagnosis, therapy

• Speech difficulties associated with

cleft / VPI• Principles of speech assessment• Good practice in the speech management of

children with cleft palate and VPD • Importance of a Team approach

Team work

Surgeons, dentists, specialist nurses, Speech and Language Therapists, psychologists, audiologists

collaborate in the care of the child with cleft throughout childhood