Cleft Palate Speech-Components and Assessment Voice and Resonance Disorders-ASLS-563. Key Components of Cleft Palate Speech.

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1 Cleft Palate Speech-Components and Assessment Voice and Resonance Disorders-ASLS-563 Key Components of Cleft Palate Speech Disorder Type of Disorder/ Causes Hypernasality Resonance Disorder insufficiency (VPI) or velopharyngeal incompetence Most noted with larger velopharyngeal openings Fairly large orolnasal fistula Hyponasalsity and Denasality Resonance Disorder An obstruction in the nasopharynx or nasal cavity including: narrowing or reducing the size of the nasopharyngeal space during surgical procedure to correct VPI or craniofacial conditions Can occur due to apraxia of speech caused by difficulty coordinating velopharyngeal Characteristics Abnormal coupling of oral and nasal cavities during speech Speech sounds muffled or mumbled Associated with speech sounds that are phonated More perceptible in vowels (more noted on high vowels than low vowels) In mild-to-moderate hypernasality, nasalization of phonemes is common (predominate use of nasal sounds) Hypernasality on vowels and nasalization on phonemes increases in connected speech Hyponasalsity-blockage in the nasopharynx or nasal cavity causing a reduction in normal nasal resonance during speech Denasality-total nasal airway obstruction Speech sounds stuffed up Affect production of nasal consonants (/m/, /n/, /ng/) Nasal consonants sound similar to their oral phoneme cognates (b/m, d/n, g/ng)

2 movements with anterior articulation Cul de Sac Resonance Resonance Disorder Structural abnormality, particularly a blockage of one of the resonating cavities Very large tonsils Scar or obstruction on the pharyngeal wall in the hypopharynx Combination of VPI and blockage of the nasal cavity Transmission of acoustic energy is blocked Sound is trapped in a blind pouch with only one entrance and no other outlet Mixed Resonance Resonance Disorder insufficiency Blockage of nasal cavity Nasal air emission Irregular adenoid tissue Nasal Air Emission The presence of a leak in the velopharyngeal valve or oronasal fistula during an attempt to build up intraoral air pressure for the production of consonants Speech is perceived as muffled Sounds quality is low intensity Has been described as potato-in-the-mouth A combination of any of the following: hypernasality, hyponasality, denasality, and Cul de Sac resonance Common in individuals with apraxia Different types of resonance do not occur simultaneously, they occur at different times in connected speech Most noted on pressure-sensitive phonemes (plosives, fricatives, and affricates) o Does not occur in the production of vowels or semivowels Often occurs with hypernasality, but can also occur with normal resonance

3 Nasal Grimace Weak or Omitted Consonants Short Utterance Length Altered Rate and Speech Segment Durations Airflow is released through the nose causing a disruption in the aerodynamic process of speech An overflow of muscle reaction that occurs with extreme effort to achieve velopharyngeal closure Reduced amount of air pressure in the oral cavity when producing consonants due to air flowing through the velopharyngeal valve or an oronasal fistula Reduction of oral air pressure available for connected speech due to significant nasal air emission from an unobstructed opening Increased respiratory effort and the need to take more frequent breaths to compensate for rapid loss of air pressure through the Can be loud (small velopharyngeal opening), soft (fairly large opening) or inaudible Often accompanies significant nasal emission Seen as a muscle contraction just above the nasal bridge or at the side of the nares Usually disappears spontaneously once velopharyngeal function is corrected Consonants are weak in intensity and pressure o The greater the nasal air emission, the weaker the consonant o Expected primarily with the unobstructed form of nasal emission May cause consonants to be omitted completely Speech will sound muffled or indistinct Utterance length is shortened and connected speech is choppy More frequent breaths are required for replacing air pressure Respiratory volumes may be twice that of normal speakers due to the attempt to raise intraoral pressure by increasing airflow rate during consonant production o Speech is physically difficult o Individual becomes fatigued during speech Speech segment durations are abnormal Utterance productions are longer Individuals with hypernasality have longer voice onset times

4 Compensatory and Obligatory Articulation Productions Dysphonia nose Insufficiency Hpernasality, nasal air emission, weak consonants, and short utterance length that are a direct result of a velopharyngeal or palatal opening History of congenital anomalies or VPI Vocal nodules Passive speech characteristics or obligatory errorsthe product of structural abnormality Require surgical or prosthetic intervention for correction Active speech characteristics or compensatory errors-manner of production is maintained but place of articulation is altered and moved posteriorly to the pharynx or larynx Under the patients control and can be modified with speech therapy Types of obligatory and compensatory articulation productions: Middorsum palatal stop (palatal-dorsal production) Generalized backing Velar fricative Nasalization of oral consonants Nasalization of vowels Nasal snort Nasal stiff Pharyngeal plosive Pharyngeal fricative Pharyngeal affricate Posterior nasal fricative Glottal stops Substitution of /h/ for voiceless plosives Breathiness Breathiness, hoarseness, low intensity, and/or glottal fry during phonation Hyperfunctional voice disorder in individuals with

5 Kummer, 2008 Laryngeal anomalies Congenital malformation syndromes mildly impaired velopharyngeal valving due to increased respiratory and muscular effort in attempt to close the velopharyngeal port which causes thickening and edema of the vocal folds leading to vocal nodules Essential Components of Assessment for Cleft Palate Speech - Formal and Informal Assessment Diagnostic Interview Language Screening Description/Purpose Obtain Background Information Questions can include information about: o Current concerns o Articulation o Resonance o Language o Medical History o Developmental History o Feeding and Oral-Motor Skills o Airway o Treatment History Language screening can be done by using a parent questionnaire Informal language screening can be done by: o Observing play behavior, gestures, spontaneous vocalizations and utterances o Asking the child to follow commands or point to objects o Listening to spontaneous speech o Asking questions or asking for explanations o Having child repeat sentences Formal language screening o Birth to 3 years Receptive-Expressive Emergent Language Scale (REEL), Early Language Milestones (ELM), Rossetti Infant Toddler Language Scale

6 Speech Samples Perceptual Evaluation Low-Tech and No-Tech Evaluation Procedures o 2 to 6 years The Fluharty Preschool Speech and Language Screening Test Formal articulation tests o To determine the cause of the speech problem (structure versus function) and provide data to develop appropriate treatment plan for therapy Syllable repetition o To isolate effects of other sounds and to determine if there is phoneme-specific nasal air emission o Pressure sensitive phonemes are tested with both a low and high vowel to determine if hypernasality occurs more on high vowels than low vowels, or is vowel specific Sentence repetition o Can easily test articulation, nasal air emission, and resonance in the connected speech environment Counting and rote speech o Have the child count or recite the alphabet Spontaneous connected speech o To assess articulation and resonance in connected speech o Connected speech increases the demands on the velopharyngeal valving system to achieve and maintain closure Make sure to evaluate: Articulation Stimulability Nasal Air Emission Weak Consonants Short Utterance Length Oral-Motor Resonance Phonation Visual Detection o Mirror Test, Air Paddle, See Scape Tactile Detection

7 Orofacial Examination Nasometry Aerodynamics Radiography/Imaging o Feeling the sides of the nose Auditory Detection o Nose Pinch (Cul de Sac) Test, Stethoscope, Straw, Listening Tube Visual inspection of the oral cavity to evaluate the orpharynx, velar morphology and mobility, and the tonsils (in some cases the epiglottis can be seen) Observe the following: o Spacing between the eyes o Shape and location of the ears o Nose and airway o Facial bones and profile o Lips (bilabial closure at rest and during speech) o Hard palate-observe the mucosa, incisive papilla and rugae, position of alveolar ridge, and palatal vault o Velum and uvula to determine velar integrity and look for characteristics of a submuccous cleft o Epiglottis in young children o Posterior and lateral pharyngeal walls o Tonsils o Dentation and occlusion o Tongue (structure and function) o Oro-motor function-tongue, lips, and sequence of motor movements for speech Nasometer-measures the relative amount of nasal acoustic energy in an individual s speech Used to evaluate resonance and velopharyngeal function Should not be used as an independent diagnostic measure Pressure-flow technique is used to gather information regarding velopharyngeal function and respiratory parameters Lateral Cephalometric X-ray o Radiographic images of the midsagittal plane of the head o Shows the hared palate, velum, an posterior pharyngeal wall o No longer used for routine assessment of velopharyngeal function Magnetic Resonance Imaging o Effective method for seeing the anatomy of the levator veli palatini muscle and

8 related structures, diagnosing an occult submucous cleft palate, and has been suggested for evaluating velopharyngeal function Videofluoroscpy Nasophaygoscopy Kummer, 2008 Displays structures and function of the velopharyngeal mechanism In order to view all aspects of the velopharyngeal sphincter, many views must be obtained including: o Lateral view o Frontal view o Base view o Towne s view o Oblique view Used for evaluating velopharyngeal dysfunction o Can identify the cause as well as the size and location of the opening o Can detect the presence of an obstruction in the vocal tract Provides a view during speech of the nasal surface of the velum and all of the structures of the velopharyngeal valve

9 References Kummer, A. W. (2008). Cleft palate and craniofacial anomalies: Effects on speech and resonance (2 nd ed.). Clifton Park, NY: Delmar Cengage Learning.

Financial Disclosures

Resonance Disorders and Velopharyngeal Dysfunction: Evaluation and Treatment Ann W. Kummer, PhD, CCC-SLP Cincinnati Children s Hospital Medical Center Employment: Financial Disclosures Cincinnati Children