Cleft Palate Speech-Part 2: Assessment, Intervention and Medical Referrals Related to the School-Aged child With Cleft P

1. 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 Manager, Foothills Speech and Language LLC Children’s Hospital Colorado, Cleft Lip and Palate Team Consultant www.foothillsspeech.org

2. Structure Vs. Function • The Bridge to Nowhere

3. 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+

4. Assessment of Structure and Function • The head and face • The lip and nose • The Alveolar Ridge/anterior palate • The Mid Palate • The soft Palate

5. The Head and Face Structure Function • Facial and cranial Nerve Tests • Symmetry of smile • Lip strength • Blink eyes • Strength against resistance • Lingual mobility • Palate mobility • Swallow • Gag reflex • Visual alignment of parts • Use a tongue blade

6. The Lip and Nose Structure 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/ • Nasal symmetry • Septal deviation • Turbinate hypertrophy • Columella length • Lip symmetry • Labial frenulum • Lip rounding

7. The Alveolar RidgeAnterior Palate Structure Function Airflow distortion Poor lingual placement Nasal emission Mid-dorsal placement Obligatory errors Occlusion Class III Aberrant sounds (sucking air through fistula) • Lateral segment collapse • Fistula (multiple) • Tooth in palate • Dental decay

8. Assessing Palatal FistulaDoes it effect velopharyngeal function?

9. Tools for Assessment

10. 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

12. 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.

13. The Mid Palate Structure Function Nasal Emission Mid dorsal stops Backing errors Food/liquid in palate Effect on resonating space • Fistula • May not be able to obturate • Arch height • Scaring

14. “The Crux of the Biscuit”The Posterior Palate Structure Function Velopharyngeal Dysfunction Velopharyngeal Insufficiency Velopharyngeal Inadequacy Velopharyngeal Incompetency Neurologic component Velar notching Snoring/OSA • Short Palate • Immobile Palate • Incomplete resection of Levator • Dehiscence • Fistula • Tonsil/adenoid hypertrophy

15. Assessment • YOUR EARS!!!!!!!!!!!!!!! • Rating Scales • Nasometry • Nasopharyngoscopy • Videoflouroscopy • Still x-ray of “eeeee” 20% require secondary management

16. Rating Scales

17. Speech Scales

18. Treatment Vs. Medical Management Pharyngeal Fricatives • Compensatory Mis-articulation Patterns Fistula Hearing loss VPD ADHD Hypernasal snoring More therapy • Nasal Emission Glottal Stops

19. TreatmentThe Speech Sample Pepperoni Pizza Pick up the puppy Take a turtle to lunch Daddy ate the Doughnuts Daddy does the dishes Chuggachuggachoochoo Find the funny fox Go get cake and cookies Susy slipped on the ice

20. Speech SampleLow Pressure Sentences Hi how are you? Where are you? I love you. I have a yellow yoyo. Oh wow. Sustained vowels

21. Who’s Ready to Play? • Conceptual awareness • The right Timing • Coaching versus Teaching • Inspiring!!!

22. Conceptual Awareness(For the Player) Door Closed Mouth Talking Door Open Nose Talking

24. Conceptual Awareness(For the Parent)

25. 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

26. 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.

27. 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

28. 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

29. 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

30. 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

31. 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

32. 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

33. 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?

34. 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

35. Praat(/s/ nasal fricative)

36. Praat(ba…mba)

37. 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.

38. Jeff Steffen www.foothillsspeech.org jeff@foothillsspeech

39. Question self and others

40. Inspire !!!

41. Thank you (and enjoy)