Voice Therapy of Cleft Palate

1. Voice Therapy of Cleft Palate 10言听 蔡静雯 李伟 杨丽洁

2. Topics • What is Cleft Palate? • definition • development • Incidence • Etiology • Classification • Symptoms • Repair • Acoustic Characteristics • Speech Therapy

3. part 1 What is Cleft Palate? • * definition • * development

4. What is Cleft Palate? • a kind of facial cleft* • * facial cleft: Tissier1973 numbers the clefts from 0 to 14. 4 of the most common ones: lateral cleft（面侧裂）, oblique cleft（面斜裂）, cleft lip(palate)（唇/腭裂）, median cleft（面正中裂）

5. What is Cleft Palate? • congenital malformation of embryonic origin （先天性胚胎畸形） • occurs by itself or together with an alveolar or lip cleft（齿槽或唇裂）

6. What is Cleft Palate? • how is the cleft palate comes to be ? • incomplete development in the early weeks of pregnancy • the face is being formed - the top and the two sides develop at the same time and grow towards each other, finally fusing（融合） in the middle. • The lip and primary palate develop at 4 to 6 weeks of gestation, while the secondary palate develops at approximately 9 weeks.

7. part 2 Incidence • * racial difference • * sex difference • * differences in types

8. Incidence • 1/750(safe & conservative estimated) • Cleft Palate alone: 1/2,500 according to reports from ADA. • racial difference:[by Vanderas(1987)] • [these differences could be attributed to environmental and genetic factors ]

9. Incidence • sex difference * CLP: twice as often in males than females / more severe deformities * CP: females are more than or equal to males • differences in type * varies, but hovers around a 3:3:4 ratio

10. part 3 Etiology • * some related causes

11. Etiology Unknown • parental age （孕龄） • drug use （药物） • infections during pregnancy （孕期感染） • smoking or/and drinking during pregnancy • heredity , Family History （遗传） • X-ray,microwave （辐射） • deficiency of vitamin C,D,B （维生素C\D\B缺乏） • environmental Factors （环境） • Animal models have demonstrated that vitamin A, corticosteroids, and phenytoin produce cleft palate when given in pregnancy. （维A多度使用）

12. part 4 Classification • * soft palate alone • * incomplete • * complete

13. 2 1 3 4 Classification • 1- Cleft of the soft palate only（软腭裂） • 2- Incomplete cleft of palate(unilateral/bilateral): not extend into the nose • 3,4- Complete cleft of palate(unilateral/bilateral): extend into and involves the nose

14. Classification 1- Cleft of the soft palate only

15. Classification 2-unilateral Incomplete cleft of palate

16. Classification cleft palatetogether with an alveolar or lip cleft cleft palate only 3-unilateral complete cleft of palate

17. Classification cleft palatetogether with an alveolar or lip cleft cleft palate only 4-bilateral complete cleft of palate

18. part 5 Symptom • * 5 of the symptoms

19. Symptom • Separation of the palate * Velopharyngeal closure During speech and swallowing the palate moves both superiorly and posteriorly against the posterior pharyngeal wall to separate the oral pharynx and nasal pharynx. When palate is cleft ,however, not only is there inadequate Velopharyngeal closure but, in addition , the opening in the palate permits the air stream to pass partly through the nose. Thus ,the air stream ,passing through both nasal and oral cavities, can not be altered properly to produce the normal sounds. • Speech and/or language problem: Nasal voice* • Recurrent ear infections • Nasal regurgitations during bottle feeding（喂奶时鼻腔返流） • Psychological problems: of the adolescent or adult patients and their families.

20. Symptom • Nasal regurgitations during bottle feeding（喂奶时鼻腔返流） • A cleft feeding nipple must have: • 1 a large enough opening to allow the formula to flow easily to prevent sucking fatigue, but it must not be so large as to cause choking. • 2 Nipples should be soft and compressible（可压缩）, allowing liquid to flow easily. • 3 the hole in the nipple designed for a premature neonate may need to be enlarged to increase the flow of milk( performed by creating an X-shaped opening)

21. Symptom • Nasal regurgitations during bottle feeding（喂奶时鼻腔返流） squeeze the bottle in conjunction with the baby's sucking/breathing rhythm to assist with swallowing

22. part 6 Repair • * the goal • * the age • * the procedures

23. Repair • The goal: to create a velopharyngeal valving mechanism that is capable of seperating the oral from the nasal cavities during speech.[primary goal] • added benefits: easier intake of food, reduction in the number of upperrespiratoryinfections, and improvment to the status of the middle ear. • for parents: experience a psychological lift when the cleft is repaired

24. Repair • The age: The optimal timing for cleft palate repair is controversial. * In China: most commonly at 1.5 to 2 years old.【体重在12公斤以上，WBC（白细胞）在10,000以下，血红蛋白在10克以上，无发热﹑咳嗽﹑流鼻涕现象。】 With this approach, the part of the palate necessary for normal speech development is intact, but without the growth restriction of closing the hard palate. a two-stage repairhas been proposed. Involves: *closure of the soft palate between 6 to 12 m [ creates a functional palate, reduces the chances that fluid will develop in the middle ears, and aids in the proper development of the teeth and facial bones ] *closure of the hard palate between 15 to 18 m

25. Repair • How: • before the surgery: # a speech therapist or feeding therapist -- feed the child to gain weight and be healthy # test blood / take medical history / physical examinations # 10 days before: stop taking some drugs like Aspirin # on the day: arrive on time / give a small sip of water / make sure the child's health

26. Repair • How: • during the surgery: 2 or 3 hours: # have general anesthesia (asleep and not feeling pain)（全身麻醉） # two main types of the surgery: * palatoplasty（腭成形术） * pharyngoplasty（咽成形术） Both palatoplasty and pharyngoplasty be performed to recover the anatomy and physiological function of the palate.

27. Repair • How: • during the surgery: * palatoplasty（腭成形术）：利用裂隙邻近的组织瓣封闭裂隙、延长软腭，将移位组织结构复位，以恢复软腭的生理功能。【单瓣手术、多瓣手术(以两瓣常用)、梨骨瓣手术、岛状瓣手术、逆向双“Z”形瓣手术、提肌重建术】

28. Repair * palatoplasty（腭成形术） 松弛切口线 剖开裂隙边缘 分离粘骨膜瓣 游离血管神经束 局部浸润 拨断翼钩 剪断腭腱膜 分离鼻腔黏膜 分层缝合 松弛切口填塞

29. Repair * palatoplasty（腭成形术）

30. Repair • How: • during the surgery: * pharyngoplasty（咽成形术）：利用咽后壁组织瓣，增加软腭长度和咽侧组织瓣缩小咽腔宽度，以改善腭咽闭合。【咽后壁组织瓣手术和腭咽肌瓣手术】

31. Repair * pharyngoplasty（咽成形术）： 分离咽后壁组织瓣 切口设计 局部浸润麻醉 关闭咽喉壁创面 示缝合后口腔面 示缝合后矢状面

32. Repair * pharyngoplasty（咽成形术）：

33. Repair • How: • after the surgery: # be in the hospital for 5 to 7 days / Complete recovery can take up to 4 weeks. # surgery wound be kept clean / not be stretched / not have any pressure 3 to 4w # when heals, on a liquid diet # wear arm cuffs to limit arm movement / no putting in mouth

34. part 7 Acoustic Characteristics • * VPD • * compensatory speeche errors

35. Acoustic Characteristics • Children with a histroy of cleft palate are at risk of for resonance and speech problems due to velopharyngeal dysfunction (VPD，腭咽闭合功能不全), there are 3 main types of VPD: • Velopharyngeal Incompetence • Velopharyngeal Insufficiency (VPI) • Velopharyngeal Mislearning: This type of VPD will most likely respond to speech therapy

36. Acoustic Characteristics • VPD due to incomplete closure of the velopharyngeal valve may include: • Hypernasality（鼻音功能亢进） • Nasal Air Emission（鼻漏气） • Nasal Rustle/Turbulence（鼻湍流） • Weak or omitted consonants. • Short utterance length（句长缩短） due to loss of air through the nose. • Compensatory speech errors（代偿性发音） • Phoneme-Specific Nasal Emission of Air

37. Acoustic Characteristics • VPD due to a blockage or obstruction（阻塞） may include: • Hyponasality（鼻音功能低下） • Cul-de-Sac Resonance（共鸣困难）

38. Acoustic Characteristics • Compensatory speech errors（代偿性发音）: These errors are often attempts to adjust for nasal air loss. • speech sound distortions（语音失真） • glottal stops （声门塞音） • nasal substitutions（鼻音替代） • pharyngeal fricatives and stops（咽擦音、咽塞音）

39. part 8 Speech Therapy • * Relaxations • * Methords related to • certain problems

40. Speech Therapy 放松训练 针对性训练

41. Speech therapy • Relaxations（放松训练）: • 按摩手术瘢痕及冰冻刺激促进瘢痕软化 * 增加软腭的长度 * 改善腭咽部肌肉软组织感觉和运动功能 • 练习发“啊”音，打哈欠，发音时双肩伸直用力推前面的桌子 * 抬高软腭，使悬雍垂与咽后壁接触 • 指导患儿练习口唇和舌的肌肉活动【口部运动操】

42. Speech therapy • Methords related to certain problems（针对性训练）: 1 腭咽闭合功能训练Velopharyngeal function training • 气流传导异常的矫治： * proper air flow location（气流部位的识别、正确气流部位的建立） * 采用听觉视觉触觉等 • 口鼻呼吸分离训练法：帮助建立正确的口鼻腔气流意识 * CPAP(continuous positive airway pressure) * 锻炼腭咽部结构，提高软腭上抬的意识和力量 • 口腔共鸣法：发音时口腔充分打开，体会气流从口腔流出的感觉

43. Speech therapy • Methords related to certain problems（针对性训练）: 2 增强节制呼吸功能训练，提高言语呼吸功能Improving respiratory function • 提高肺活量，增加句长： * 用力呼气训练、缓慢呼气训练 * MPT、MCA * 停顿换气训练 • 提高呼吸支持能力，控制能力和言语呼吸功能 * Combine with DR.Speech S1.S2.S5

44. Speech therapy 3 强化正确的构音器官运动训练，纠正因不良代偿发音习惯而引起的功能性语言障碍Correct Compensatory speech errors • 根据错音的类型进行口面构音器官的运动训练 * 采取练舌法和练唇法。 • 舌后缩习惯的矫正 * 压舌板 or 汤匙柄 or 咬舌发音 * 伸舌法 / 前位音法 • 纠正错误的发音 * the same as articulation therapies * 发音部位、发音方式异常的矫治

45. Speech therapy • Methords related to certain problems（针对性训练）: 4 Phychotherapy （心理治疗）run throught from the beginning to the end. • for both the children and the family

46. Thank You !