1. CSD 2230 HUMAN COMMUNICATION DISORDERS
Topic 7
Speech Disorders
Cleft Lip and Palate

2. Major Landmarks of the Vocal Tract
Disorders involving cleft lip and palate involve the lips, hard palate, and the velum

3. The Palate Anterior 2/3 is the hard palate
Stationary
Purpose is to separate the oral and nasal cavities
Posterior 1/3 is the soft palate
Mucosal tissue and muscles
Recall from our lectures of the anatomy of the vocal tract we identified the palate
Show some slides.
The front 2/3 of the palate is the hard palate (bone). Fused together in the middle and is stationary and its purpose is to separate the oral and nasal cavities (at least the front aspects). The hard palate is covered by a mucosal lining.
The soft palate (velum) covers the back 1/3 of the palate and is made of mucosal tissue and muscles

4. Velopharyngeal Mechanism
Components
Velum
Muscles in the back of the throat
The velopharyngeal mechanism is the velum and the muscles in the back of the throat. The mechanism acts like a valve. When it’s open, it allows coupling between the oral and nasal cavities. When it’s closed, the oral and nasal cavities are closed.

5. The Purpose of the Velum
The velum needs to be closed and the oral and nasal cavities separated when we swallow and during the production of most English speech sounds
The velum needs to be closed, and the oral and nasal cavities separated when we swallow and during the production of most English speech sounds. The velum is closed by muscle contraction that moves the velum up and back, so it makes contact with the pharynx.

6. Some Terms and Definitions
Velopharyngeal Competence
The velopharygeal mechanism adequately closes the portal during swallowing and speech
Velopharyngeal Incompetence (VPI)
The velopharyngeal mechanism is incapable of separating the oral and nasal cavities during swallowing and speech
Velopharyngeal competence means that the velopharyngeal mech adequately closes the portal during swallowing and speech.
Velopharyngeal incompetence (VPI) means that the mechanism is incapable of separating the oral and nasal cavities during swallowing and speech. VPI is a major problem with cleft palate, which is a major type of craniofacial anomaly that has profound implications regarding the communication abilities of a child. This is the only craniofacial abnormality we will look at.

7. Embryologic Development of the Face and Palate
Formed between the 5th and 8th weeks of gestation
Results from the fusion of
Two mandibular processes
One frontonasal process
Two maxillary processes
Cleft lip occurs when the fusion process between the frontnasal masses and the maxillary processes is interrupted
CD-ROM Ch morphing sequence depicting embryologic development of the human face
Development of the face and Palate:
Before we talk about the underlying nature of clefts and the different types there are, we need to look at the normal develelopment of the face and palate during the embryological period.
Facial development: the face and the anterior (front) aspects of the mouth are formed between the fifth and eighth weeks of gestation. Normal development of the face and mouth is a result of a complex fusion of 5 different embryonic processes
 Mandibular process x 2
 Frontonasal process
 Maxillary process x 2
Fusion of the two mandibular processes forms the mandible and lower lip and occurs during weeks They grow toward each other and fuse at the midline
During week 5, the frontonasal process grows in a downward direction and separates into 2 distinct tissue masses on each side of the face. These masses eventually fuse with the maxillary processes to form the nostrils, the anterior aspects of the face just beneath the eyes, the anterior portion of the upper lip, alveolar ridge, and the hard palate.
Facial development is done during week 8
Cleft lip is thought to occur when the fusion process between the frontonasal masses and the maxillary processes is interrupted either by genetic causes or by environmental agents.
Show CD-Rom morphing example

8. Embryologic Development of the Face and Palate
Development of the secondary palate
Bony hard palate and the velum
Process and fusion occurs between the 8th and 12th week of gestation
Problems or factors that prevent fusion of the palatal shelves result in an isolated cleft of the hard and/or soft palate
Development of the secondary Palate:
The secondary palate includes the bony hard palate and the soft palate. Between 8-12 weeks gestation, embroyonic processes that give rise to the hard and soft palate will fuse, separating the oral and nasal cavities.
The hard and soft palates arises from 2 palatal shelves that grow downward from the maxillary process. They eventually meet and fuse together from the front of the palate to the back. The muscles of the soft palate also arise from these palatal shelve.
The fusion of all aspects of the secondary palate are complete by the end of the 12th week. Problems or factors that prevent fusion of the palatal shelves will result in an isolated cleft of the hard and/or soft palate.

9. Classification of Clefts and Clinical Features
Clefts are classified as
unilateral or bilateral cleft of the lip
unilateral cleft of the lip and palate
bilateral cleft of the lip and palate
submucous cleft
bifid uvula
Kinds of clefts and clinical features:
This is a disorder with a continuum in type and severity ranging from a small v-shaped notch of the lip to a complete separation of the upper lip, dental arch, and the R and L sides of the hard and soft palate.
Clefts are classified as
1. unilateral or bilateral cleft of the lip
2. unilateral cleft of the lip and palate
3. bilateral cleft of the lip and palate
4. submucous cleft
5. bifid uvula
Let’s look at each in tun, that some of their clinical features:

10. Cleft Lip
Involves the vermilion border of the upper lip and may extend through the lip toward the nostril
Affects the shape of the nose
Can be either unilateral or bilateral
Unilateral clefts usually occur on the left side
Bilateral clefts usually involve the palate
Cleft lip by itself is rare
Cleft lip: this involves the reddish portion of the upper lip and may extend thru the lip toward the nostril. A complete cleft of the lip would continue thru the upper lip into the floor of the nostril.
A cleft lip will affect the shape of the nose. The nose will be flat, the nostrils assymetrical, and the strip of tissue connecting the base and tip of the nose will be short and misaligned.
Clefts of the lip can be on one side (unilateral) or on both (bilateral).
Unilateral clefts usually occur on the L side.
Bilat clefts usually involve the palate too.
Cleft lip by itself is rare (only 5% of cleft cases).

11. Unilateral and Bilateral Cleft Lip and Palate
Extends from the external portion of the upper lip, through the alveolar ridge, and through the hard and soft palates
Bilateral
The lip and the alveolar ridge is cleft under both nostrils and the central portion of the lip, alveolar ridge, and the premaxilla are positioned abnormally
The tip of the nose is attached directly to the lip
Most severe form of cleft
Unilateral cleft of the lip and palate: extends from the external portion of the upper lip, thru the alveolar ridge, and thru the hard and soft palates.
Bilateral cleft of the lip and palate: the most severe type of cleft due primarilty to a severe tissue deficiency. The lip and the alveolar ridge is cleft under both nostrils and the central portion of the lip, alveolus, and the premaxilla is positioned abnormally as a mass of tissue. The tip of the nose is attached directly to the lip

12. Submucous Cleft and Bifid Uvula
Muscular cleft of the soft palate
A bifid uvula sometimes accompanies this
Submucous cleft: muscular cleft in the region of the soft palate. Cleft is covered by a thin layer of mucosal tissue that can sometimes hide it. A bifid (split) uvula may indicate the presence of a submucous cleft. Another landmark is a bluish color in the middle of the soft palate—that’s why during the oral exam we’ll shine a light in the nose and see if there’s evidence of this coloration in the soft palate—the muscles of the soft palate fail to fuse.

13. Etiologies Genetic disorders Chromosomal aberrations
Factor in over 400 different genetic syndromes
Chromosomal aberrations
Teratogenically induced disorders
Environmental teratogens are agents that interfere with or interrupt normal fetal development
Mechanically induced abnormalities
Amniotic rupture, intrauterine crowding, uterine tumors, irregularly-shaped uterus
Etiology
We know that clefts result from a fusion failure during the embryonic stage of development, but what causes these structures to not fuse?? There are 4 reasons for this:
Genetic disorders:
Clefting is a factor in over 400 different genetic syndromes (other things are wrong as well). Many of these syndromes are well known.
Chromosomal Aberrations
A rare condition, Trisomy 13, results from the appearance of a third #13 chromosome. A cleft lip with or w/out cleft palate will most likely result.
Teratogenically induced disorders:
Environmental teratogens are agents that interfere with or interrupt normal development of a fetus and create congenital malformations.
Teratogens associated with clefting included drugs (dilantin, thalidomide, aspirin, and retinoids), alcohol, nicotine, and caffeine.
Xrays, certain viruses.
The effects of teratogens can vary with the mother’s genetic makeup, the time of exposure during pregnancy, the amount, and the mother’s metabolism.
Mechanically induced abnormalities: The most frequency cause of mechanically induced clefts is amniotic rupture (loss of amniotic fluid), intrauterine crowding (multiple fetuses), uterine tumors, or irregularly shaped uterus.

14. Incidence 1/750 live births
Clefts of the lip (with or w/out involving the palate) occur more frequently than cleft palate alone
Submucous clefts are more rare (1/1200 births)
The incidence of clefts are thought to be increasing
Clefts occur more often in males and tend to be more severe
Native north Americans have the highest incidence rates followed by Asians, Caucasians, and Africans
Incidence: 1/750 live births. Clefts of lip (with or w/out involving the palate) occur more frequently than cleft palate alone. Submucous clefts are more rare (1/1200 births). The incidence of clefts are thought to be increasing.
Clefts occur more often in males and tend to be more severe. Native north Americans have the highest incidence rates followed by Asians, Caucasians, and Africans.

15. Management of Clefts Team approach Management:
Very much a team approach. This is a disorder that has a long-term and ongoing management need. Different specialties will be needed at different times. SLPs and audiologists are members of the team because of the communications problems that are inherent with clefts.

16. Surgical Management Primary correction Secondary correction
Lip surgery by 3 months
Palatal cleft surgery by 6-18 months
Secondary correction
Pharyngeal flap
25% of cases
Improves velopharyngeal competence
Done between 6-12 years of age
Surgical management: occurs in 2 major stages.
Primary correction—lip surgery occurs first, usually before 3 months. Surgical correction of a cleft palate is designed to create a velopharyngeal valve capable of separating the oral cavity from the nasal cavity during speech. Early surgical closure of the palate also improves swallowing and reduceds the number of middle ear and respiratory infection. Palatal cleft is surgically closed between 6-18 months.
Secondary correction—about 25% of the primary surgery cases still show VPI. If this is the case, then a pharyngeal flap is created by cutting a flap of soft tissue from the posterior (back) pharyngeal wall, and suturing one end to the velum. Openings are maintained along the sides of the pharynx. Pharyngeal flap surgery would be done between 6-12 years.

17. Dental Management Issues related to chewing and speech Orthodontists
Prostodontists
obturators
Dental management: these people have significant dental issues related to chewing and speech production. They need orthodontists to realign the teeth and malocclusions (misaligned dental arches).
Prosthodontists are dentists concerned with the replacement of missing teeth and other oral structures with prothsetics. Sometimes people don’t undergo the palatal surgery to close the cleft. They would then see a prosthodontist to have fit an “obturator” which is a special kind of dental prosthesis designed to fill the cleft and partition the oral cavity from the nasal cavity.

18. Audiological Management
Middle ear disease
Chronic otitis media
Persistent conductive hearing loss
Audiological management: clefts are associated with higher incidence of middle ear disease Primarily occurs because the cleft interferes with the functioning of the muscles that open the Eustachian tube.
Chronic OM is a result usually with persistant conductive hearing loss.

19. Psychosocial Management
Facial differences
Speech differences
Self-esteem
Psychosocial management: even after the clefts are repaired, it’s pretty evident that the face is not normal. On top of that, there speech is likely to be affected as well. These kids encounter unusual social pressure that can affect their psych well being. These issues need to be managed.

20. Communication Problems Inherent with Clefts
80% of individuals born with clefts not associated with a syndrome who receive palatal repair by 18 months can expect reasonably good speech without intervention
Communicative problems associated with clefts:
About 80% of people born with clefts that aren’t associated with a syndrome and receive palatal repair by 18 mo can expect reasonably good speech w/out intervention. The other 20% can have extensive communication problems. Therapy is often long-term and prognosis is variable.
Here are the general kinds of problems faced:

21. Resonance Hypernasality because of VPI
Continuum from hyponasility, which is due to the lack of nasal resonance to hypernasility, which is due to too much nasal resonance and not enough oral resonance
Audio example of samples of speech representing a continuum ranging from hyponasality through very severe hypernasality
Resonance problems:
Because of the VPI, they have “hypernasal” voice quality. This is a resonance disorder, not a voice disorder and comes about because the nasal cavity isn’t separated from the oral cavity during speech. They talk thru their nose.
Nasality in speech really falls along a continuum from hyponasality (lack of nasal resonance) thru hypernasality (too much nasal resonance and not enough oral resonanace).
Play the tape example of samples of speech representing a continuum ranging from hyponasality thru very severe hypernasality.
People with VPI exhibit hypernasality of varying degrees. It’s associated mainly with vowel sounds, especially in conversational (connected) speech.

22. Articulation
Articulation disorders are the result of VPI, structural deviations in the oral cavity, dental anomolies, and faulty learning
Phonemes commonly affected include /s/, /z/, /th/, /ch/, and /ts/
Problems with oral pressure
Nasal emission
Compensatory articulation errors
Glottal stop
Artic problems:
The result of VPI, structural deviations in the oral cavity, dental problems and anamolies, faulty learning. Phonemes that tend to be misarticulated the most include /s/, /z/, /th/, /ch/, and /ts/.
Some phonemes that require a considerable build-up of air pressure in the oral cavity (stop consonants) are especially problematic because air will escape thru the nose(nasal emission). This isn’t the same thing as hypernasality. Nasal emission is audible release of air thru the nose.
Compensatory artic errors—this is a gross sound substitution error that is an attempt to compensate for the physical inability to produce a given sound correctly. A common one is a glottal stop

23. Some Audio Examples Samples 1 and 2 illustrate reduced oral pressures
Samples 3 and 4 illustrate problems related to nasal emissions
Samples 10 and 11 illustrate common articulation errors (substitutions and omissions
Sample 12 illustrates substitution of glottal stops for oral stops
Samples illustrate some unusual substitutions and distortions
Go thru Section 1 –speech characteristics caused by VPI
1 and 2 illustrate reduced oral pressures
3 and 4 illustrates problems related to nasal emissions
10 and 11 illustrate common artic errors (subs and omissions)
12 illustrates substitution of glottal stop for oral stops
13-16 illustrate some unusual substitution and distortions

24. Voice Vocal nodules Audio examples Hoarse and breath vocal quality
Caused by vocal hyperfunction
Audio examples
Samples 17 and 18 illustrate mild and severe degrees of hoarseness
Sample 19 illustrates extreme vocal tension and the use of inhalation tension
Voice problems:
Most common vocal pathology is vocal nodules, which produce a hoarse, breathy vocal quality. The nodules are thought to arise from “vocal hyperfunction” due to screaming, yelling, etc in non-cleft kids. The larynx is moved high in the neck.. This is a compensatory strategy in cleft-kids to help increase their volume.
Tape examples of some voice disorders
17 and 18 illustrate mild and severe degrees of hoarseness
19 illustrates extreme vocal tension and the use of inhalation tension.

25. Language Mild language delays Audio examples
Samples 22 and 23 illustrate problems with morphophonemic markers
Sample 24 illustrates a change of syntactic form when morphophonemic marking is too demanding
Lang disorders:
Mild lang delays are evident. Not much research available to tell us why this might be.
Some tape examples:
22 and 23 illustrate problems with Morphophonemic markers
24 illustrates a change of syntactic form when morthophonemic marking is too demanding

26. Audio Case Study of a Mild Disorder
10 year old male
Speech problems
Mild, inconsistent, bilateral nasal emission
Mild hypernasality
Moderate hoarseness
Developmental articulation errors
Omission of sibilants in consonant clusters

27. Audio Case Study of a Moderate Disorder
6 year old male
Speech problems
Consistent, bilateral nasal emission
Audible nasal air turbulence
Moderate hypernasality
Mild hoarseness
Reduction of intraoral pressure on sibilants and lateralized sibilants
Other articulation errors

28. Audio Case Study of a Severe Disorder
8 year old male
Speech problems
Severe, consistent, bilateral nasal emission
Severe hypernasality
Moderate hoarseness
Reduced intraoral air pressure
Glottal and pharyngeal substitution for plosives and fricatives