Craniofacial and VPI Related Speech Disorders Melissa Montiel, SLP

Financial Disclosure Financial Disclosure: I am receiving an honorarium from the South Carolina Speech Language Hearing Association for this presentation and is employed by MUSC. Non Financial Disclosure: No relevant non- financial relationships to disclose.

What’s the difference? Normal mechanism vs. Cleft

Mechanism differences (cleft palate) Smaller “vault” Possible malocclusion Anterior “fistula” until bone grafting Possible fistula from dehiscence

Smaller vault

Smaller Vault Articulatory deficits

Malocclusion/Midface Hypoplasia

Malocclusion Frontal sibilants (III) Difficulty with bilabials (II)

Alveolar fistula

Alveolar fistula Nasal regurgitation Nasal air emissions Palatal expander and speech

Dehiscence after repair

Dehiscence Minor NAE Nasal regurgitation

“Normal” vs Cleft related speech

Normal Errors Fronting, gliding, stopping Treated based on “age-appropriate” standard norms May or may not resolve without tx

Cleft Palate related disorders Backing Palatalizing Compensatory: Glottal stopping, other (clicking) Nasal Assimilance VPI Not likely to resolve without intervention Goals not based on age/developmental norms

Backing Producing phonemes as /k,g/ ex: -Do=goo -Two=koo -boat=goat

Backing

Backing

Backing

Palatalizing Smaller vault, less space for tongue Producing alveolar phonemes with mid-dorsal part of tongue vs tongue tip

palatalizing

Palatalizing

Glottal stopping Mechanisms way to produce pressure Bypasses the VP mechanism on exam Can be because of VPI, or could be learned Very detrimental to intelligibility

Glottal Stopping

Glottal Stopping

Glottal stopping

Glottal Stopping

Glottal stopping

Compensatory Deficits produced by child attempting to make correct sounds Clicking, guttural sounds

Clicking

Compensatory- Clicking

Nasal Assimilation Producing vowels with hypernasality or phonemes with NAE when they are in the presence of a nasal phoneme -ham pizza, the /pi/ has NAE/hypernasality due the /m/ influence

Velopharyngeal insufficiency (VPI) Velopharyngeal Insufficiency: results in “An anatomical or structural defect that precludes adequate velopharyngeal closure (the decoupling of the oral and nasal cavities) ”* Basically, one is unable to appropriately and/or fully close off your oropharynx from the nasopharynx for the purpose of speech/swallowing

VPI Hypernasality- Too much energy in the nasal cavity. (Rant about hypo vs hypernasality) Nasal air emissions Weak pressure consonants (m/b, n/d) Nasal grimacing

VPI Poor feeding/sucking as infant Trouble blowing out birthday candles Difficulty drinking through a straw Nasal regurgitation

Hypernasality vs NAE Hypernasality is too much energy resonating in the nasal cavity. Nasality describes energy. Vowels are energy. We are using the term hypernasal to describe a vowel.

NAE Most consonants have pressure, so you are listening for a nasal air emission (NAE), which sounds like snorting Can also perceive weak pressure on phonemes (m/b, n/d)

VPI

VPI

VPI

VPI

Time out: Phoneme specific Nasal Air Emission (PSNAE)

Phoneme specific Nasal air emissions (PSNAE) Deficit in which the patient is able to achieve complete closure of VP port, however s/he has developed production of specific phonemes with nasal rather than oral pressure/flow/turbulence Deficit is an error in articulation, not the VP mechanism Sibilants and affricates Inconsistent NAE

PSNAE

PSNAE

PSNAE

PSNAE

PSNAE Pick up a baby Take a teddy Go get a cookie Suzie sees horses Should I shut it Joey with a jar A chicken ate a chip (Leave Nasals out of it!)

When we refer Before surgery After surgery

When we refer Goal: -Eliminate compensatory or misuse -Work on non pressure phonemes, vowel markers -NOT nasality

When we refer After surgery -Eliminate compensatory -Estimate if this is habitual, teach oral vs nasal -May not need tx if placement was correct before surgery

Treatment Where to start? Remember, separate out deficits. Working on manner? Stick with manner.

Treatment Don’t worry about manner re: nasality with compensatories Hypernasality is not generally your goal Teach placement with turbulence Use of /m/ and /n/ Remember “puppy” may be “mummy” Eliminate compensatory strategies

Treatment Liquids and glides Approximations, vowel markers Treatment, not games. -Token therapy, telling them when it’s wrong Rapid phrases. -How phrases changes phonemic sequence.

Things to avoid No oral motor Non speech tasks for majority of session Holding nose during therapy /k,g/- sometimes

Treatment Cues for bilabials, alveolar, velars Intrusive /h/ Frontalized /s/ Blowing with /f/ Blends /t/for /ch/ and /d/ for /j/

Children work best with concrete, consistent cues Children work best with concrete, consistent cues. They change their speech by what they feel

Blowing with /f/, intrusive /h/

/s/ with intrusive /h/

Rapid phrase

/s/ with intrusive /h/

Treatment /s/

Tx of /f/

Using approximations

Treatment of backing, decreasing complexity

Tx PSNAE, using approximations

Tx PSNAE

TX PSNAE

TX PSNAE

Tx glottal stopping

Bilabials

Alveolars

Tx of /k,g/

Tx of /s/

Nasal assimilation

Tx glottal stopping

Self monitoring

Tx of compensatory

Tx of compensatory

Final result

Kummer, A.W. (2001). Cleft palate and craniofacial anomalies: the effects on speech and resonance. San Diego, CA: Singular. *

Melissa Montiel, MS, CCC-SLP 843-876-7200 montiel@musc.edu