Cleft Palate- Before the Palate Repair

1. SPEECH EVALUATION AND TREATMENT FOR PATIENTS WITH CLEFT PALATEDavid Kuehm/ Lisa Henne AJSLP -Feb 03 Reviewed by Mindy Karten Bornemann • Early primary surgery to repair the hard and soft palate is preferred (Kemp- Fincham, Kuehn, 1990) to prevent glottal stops • Glottal stops are a compensatory articulation production that is characterized by forceful adduction of the vocal folds and the build up and release of air pressure undeneath the glottis, the result is a grunt type sound • Normal language stimulation should be encouraged and parents should avoid nonsense words, speak clearly and encourge cleft palate babies to babble • Children who produce nasally produced sounds before primary palatal surgery are preferable, over glottal stops • Orally produced sounds or attempts should be rewarded and glottal stops ignored and not reinforced • Glottal stops may become habitual and difficult to change even with treatment as child gets older • Methods for treating glottal stops were discussed in this journal article

2. Cleft Palate- Before the Palate Repair • Due to the inability to produce and sequence sounds articulation and the production of oral expressive language can be affected, especially due to chronic ottis media • Shortened utterances are common and difficulties may include velopharyngeal dysfunction, dental malocclusion, oral onomalies, poor intelligibility and, less variety of sounds • Infants can be shown the physical movements of sound production with the auditory results through a tactile- kinesthetic auditory feedback loop • Infants with unprepared cleft palate demonstrate the use of nasal phonemes, glides, and the glottal fricative /h/ rather than the stop plosives ( p,b,t,d,k,g) during normal babbling.

3. After the Palate Repair • If the palate is repaired around 10 months of age- most children will have adequate structure for speech sounds • They may miss the development around 6 months for babbling but can catch up if palatoplasty is done by 12 months of age • Around 30 months of age- nasal fricatives became more prevalent with repaired clefts • Therapy must address fricative contrasts and determine if velopharyngeal dysfunction is present • Habitual compensatory productions such as glottal stops, compensatory productions and abnormal resonance as well as velopharyngeal dysfunction and phonological development must be monitored and remediated during preschool years

4. Fistula Air Pressure Evaluation • A fistula is an opening into the nasal passages through the hard or soft palate This can be identified when using a mirror and flashlight • Evaluation may include asking the child to produce “puppy” or” papa” spoken repeatedly - if mirror fogs, then air leakage may be through a fistula • With production of “cookie” or “ kaka the tongue causes contact with the hard palate in the back of oral cavity- if mirror fogs then the leakage may be through the velopharynx • Using words with nasal consonants such as “amen, an, any, mama and name “the mirror should fog and the velum should remain in an almost fully lowered position. Inadequate airflow can be caused by obstruction due to enlarged adenoids or nasal blockage due to deviated nasal septum, enlarged nasal turbinates or other physical problems

5. Treatment for Glottal Stops • Non -nasal consonants are abnormally articulated in the larynx by forcefully approximating the vocal folds instead of stopping airflow in the mouth normally • Glottal stops are perceived as brief choking or popping in the throat-obstruent. Consonants such as “p” or” s” require normal air pressure, if opening is abnormal then the air pressure cannot build • When evaluation comes later for cleft palate child - elimination of glottal stops are more difficult to treat than when treated during first months of life - • home based treatment will have better success if caregiver or parent can be trained also

6. Patient open mouth and exhale or sigh into mirror Patient makes a sustained “h” sound Patient makes a sustained “h” followed by a vowel such as a “a” the production is “hhhaaa” Patient is asked to produce “aaaahhhaaa” sustaining “a” followed by sustained “h” followed by “a” Have patient say “hhhaaapppaaa “making a light “p” contact Treatment to Eliminate Glottal Stops

7. Add other sounds alternating “aaaa” “hhh” “aaa” Child can build on nasal sounds that they can already produce Patient say “ aaa” “mmm” “aaa” with nostrils pinched closed Repeat with nostrils open then “aaa” “nnn” “aaa” with nostrils closed- will sound like“aaa” “ddd aaa”- try to make sound come from mouth not nose Have patient say then repeat with nostrils pinched closed- ask patient to say “aaa” “ggg” “aaa” with nostrils open. Then instruct them to have sounds come from the mouth and not from the nose Generalizing Correct Production

8. Treatment for VPI • Hypernasality may exist independently of glottal stops or other compensatory articulations • Blowing bubbles and balloons are not effective in treating VPI - Less severe VPI may be treated successfully with treatment such as continuous positive airway pressure • Secondary surgery procedures such as pharyngeal flap or sphincter pharyngoplasty are most successful • Surgery can be performed as soon as child has a consistent and stable speech sample which is obtained at about 3-4 years

9. Behavioral Treatment • CPAP treatment ( Kuehn, 1997) or resistance exercise approach to strengthen the velo-pharyneal musculature • The gap must be less than 2 mm or if the velum moves fairly well, and hypernasality is mild to moderate • Procedure may be done after pharyngeal flap or sphincter pharyngoplasty if mild to moderate hypernasality persists. • Efficacy data to support that these behavior treatments have positive results is lacking • A teams of professionals should manage cleft palate clients-

10. Other Therapy Programs • Music Therapy program was recently established to allow CP children to increase oral motor skills and articulation • http://www.orthohospital.org/press/020410_1.html • Targeting specific speech sounds and less drill work makes remediation more enjoyable and less threatening. Also increases confidence in social settings Group meets once a week for an hour - children integrated with unimpaired students. A variety of music activities are used which gives children a new means of working on speech patterns Symbolic play and language therapy found positive correlations between a number of play variable at 18 months and Mean length of utterance at 24 and 30 months of age. Early play gestures may help therapists to identify children who may be at risk for future language impairments .

11. References • Kuehm Speech Evaluation and Treatment for Cleft Palate- American Journal of speech Pathology and Audiology- Volume 12 Pages 103-110 February 2003 www.mayoclinic.com- good overall resource on cleft palate- retrieved 2/25/04 www.healthscout.com//template.asp?pages=searchResults&ap=1- cleft palate general information- retrieved 3/10 04 • http://nymetro.com/nymetro/news/features/n_9678 • Article on twins with cleft palate and taping of lips-retrieved 3/ 31/04 • Kummer, Ann Cleft Palate and Craniofacial Anomalies Effects on Speech and Resonance, 2001 • Snyder-L, Scherer N- American Journal of Speech Language Pathology- Volume13 Pages 66-80 February 2004 • -