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

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 Nose Structure 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 Ridge Anterior 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 Fistula Does 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 fistulae Considerations 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

Treatment The Speech Sample Pepperoni Pizza Pick up the puppy Take a turtle to lunch Daddy ate the Doughnuts Daddy does the dishes Chugga chugga choo choo Find the funny fox Go get cake and cookies Susy slipped on the ice

Speech Sample Low 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)

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 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/2 nd opinion Write update as to why management.

Jeff Steffen

Question self and others

Inspire !!!

Thank you (and enjoy)