Let s start by tuning our ears!

Craniofacial Speech Disorders: How to Identify, Transcribe & Plan Treatment Let s start by tuning our ears! Judith Trost-Cardamone, PhD - CCC/SLP, FASHA Professor, California State University-Northridge judith.e.trost-cardamone@csun.edu 1 2 Craniofacial Speech Disorders: A Description typically occur in individuals with craniofacial anomalies (e.g., CLP) affect articulation, resonance, or both can be obligatory (requiring physical management and generally not responsive to speech therapy) OR learned (requiring and responsive to speech therapy) Obligatory errors are physically-based Due to physically-based velopharyngeal (VP) inadequacy which results in Hypernasality (HN) Obligatory nasal emission (NE) Due to oral structural deviations which include Oronasal Fistulas (can be the source of NE) Dental deviations (e.g., ectopic or missing teeth) Malocclusion (e.g., Class III inverted / f, v / ) 3 4 J. Trost-Cardamone, PhD - CCC/SLP 1

Learned problems fall two groups Compensatory misarticulations Maladaptive place errors/non-oral productions Post-uvular (glottal and pharyngeal) Nasal cavity (nasal fricatives) Backed oral productions/retracted articulations Learned nasal air direction/emission VP closure Schematic lateral view Normal Inadequate Taken from: Peterson-Falzone et al., 2006 The Clinician s Guide to Treating Cleft Palate Speech 5 6 VP inadequacy can have many causes; it s not always due to cleft palate Structural deviations of orofacial/ craniofacial complex (VP Insufficiencies) Neurogenic VP dysfunction (VP Incompetencies) Phonologic patterns that simulate cleft palate speech (VP Mislearning) Exist despite a physically capable VP closure mechanism Classification of VP Function Disorders From: Peterson-Falzone, Trost-Cardamone, Karnell & Hardin-Jones (2006) * *Modified from the original publication by Trost-Cardamone (1989) 7 8 J. Trost-Cardamone, PhD - CCC/SLP 2

In our assessment, distinguishing obligatory from learned is key to accurate speech diagnosis, referral, and treatment planning Identifying and transcribing craniofacial (CF) speech disorders 9 10 Salient parameters of cleft palate speech (cleft type speech characteristics) Hypernasality (HN) Audible nasal air emission (NE) and associated weak pressure consonants Consonant production errors Compensatory misarticulations (non-oral and post- uvular placements) Glottal stops (and fricative /h/ substitutions) Pharyngeal stops, fricatives and affricates Nasal fricatives Backed oral productions/retracted oral placements 11 Hypernasality [HN] The resonance deviation we hear on vowels and vocalic consonants [glides and liquids/oral sonorants] Results from coupling of oral and nasal cavities due to problem with VP closure; unites cavities HN in CF speech disorders/clp usually has a physical basis (therefore is obligatory) Is aggravated by closed mouth speaking posture 12 J. Trost-Cardamone, PhD - CCC/SLP 3

Transcription for hypernasality Hypernasality (and NE) HN diacritic goes above the affected vowel or sonorant [ i, ɚ ] or [w, r ] [bɚ d] bird [wãɪ ɚ ] wire [See Appendix 1 for ExtIPA phonetic symbols chart (2005) which I have modified to include additional symbols] 13 14 Other resonance deviations Hyponasality (and glottal stops) Hyponasality: too little nasal resonance; coldin-the-head sound; affects vowels, sonorants and nasal consonants; can perceptually mask a VPI [bu m ] = transcription Mixed nasality: elements of both hypernasality and hyponasality; there is increased nasal cavity resistance Cul-de-sac resonance: sound is trapped by anterior nasal cavity constriction; e.g., deviated septum 15 16 J. Trost-Cardamone, PhD - CCC/SLP 4

Nasal Air Emission [NE] Airflow deviation characterized by speech airflow and emission through the nose Like HN, results from inappropriate coupling of oral and nasal cavities: coupling at the VP port due to true VPI or to mislearning coupling via the oral cavity due to a fistula Sources/causes of NE (Taken from Peterson-Falzone et al. (2006) 17 18 NAE/NE continued Audible NE Accompanies and distorts production of high pressure consonants/obstruent consonants [stops, fricatives, affricates] NE comes in a variety of forms Can be audible or inaudible Audible NE can be turbulent or non-turbulent Can be obligatory (passive) or learned (active) Audible frication Nasal turbulence is more of a snorting sound; has been referred to as: posterior nasal frication, nasal snort, nasal rustle Has been associated with small VP gaps, implicating the VP port as the source of turbulence NE accompanies, is co-produced with, any high pressure consonants in a language 19 20 J. Trost-Cardamone, PhD - CCC/SLP 5

Audible NE, reduced oral pressures Obturator appliance for oronasal fistula 21 22 Transcription for NE Non-turbulent NE, e.g., on /s/, /f/: / s /, /f / Turbulent NE: e.g., on / s /, / f / or /s/ Turbulence can also be transcribed as a superscript triangle diacritic /Δ / placed above the affected/target phoneme The official IPA Extensions symbol for turbulence is the superscript / / as shown above over the /s,f/ phonemes Δ Obligatory NE May result from VP insufficiency VP incompetency Fistulas Requires physical management Surgery Speech appliance 23 24 J. Trost-Cardamone, PhD - CCC/SLP 6

Learned NE Two error patterns you are likely to encounter in clinical practice are: Phoneme-specific nasal emission (PSNE) Persisting post-operative nasal emission Can be realized in different forms, e.g., As a nasal fricative substitution As NE co-produced with the target Phoneme Specific Nasal Emission (PSNE) [aka sound specific nasal emission] Nasal emission that is selective affects only certain pressure consonants Other pressure consonants use normal/ oral airflow Usually affects: /s, z/ + /ʃ/ + /tʃ, dʒ/# Perceptually, it is often realized as a nasal fricative substitution for the target No significant HN [occasional assimilation nasality] Corrected through speech therapy 25 26 PSNE (turbulence), no cleft PSNE We find this in children with normal VP closure ability Clinicians unfamiliar with this pattern may misdiagnose the problem as a SMCP Important to understand this problem It requires speech therapy, not physical management! 27 28 J. Trost-Cardamone, PhD - CCC/SLP 7

Persisting post-operative NE NE that persists in repaired CP speakers who have the physiologic ability to attain closure Speaker continues the old pattern of directing air into the nasal cavity Not restricted to any certain sounds, sound group Not well-documented Compensatory Misarticulations [CMAs] Learned articulatory deviations Substitution errors in place of articulation Predominantly backed articulatory placements post-uvular placements Once learned, they persist even after successful physical management Therefore, can coexist with physically adequate closure mechanism 29 30 CMAs are caused by the cleft palate Compensatory Misarticulations include: Learning to talk with broken equipment places child with a cleft at risk for early speech mislearning Early learned glottal, pharyngeal and nasal productions may persist even if there is adequate VP closure Glottal stop Pharyngeal stop Mid-dorsum palatal stop Pharyngeal fricative Pharyngeal affricate Posterior nasal fricative (turbulence) Nasal fricative (no turbulence) 31 32 J. Trost-Cardamone, PhD - CCC/SLP 8

CMAs schematic illustrations of articulatory gestures and phonetic symbols for transcription (Taken from Peterson-Falzone et al., 2006) 33 34 ExtIPA (2005) did not establish symbols for this production Official ExtIPA symbols / ħ / and / ʕ / (2005) post-date these (1981) 35 36 J. Trost-Cardamone, PhD - CCC/SLP 9

ExtIPA symbol / ʩ / (2005) post-dates this symbol (1981) 37 38 Non-oral placements for compensatory misarticulations Palatal stop symbols also are used to indicate this articulation: / c / and / ɟ / 39 40 J. Trost-Cardamone, PhD - CCC/SLP 10

Backed oral productions Include any consonant that is backed/ retracted from its normal place of production, but still remains oral For example: Mid-dorsum palatal fricative for /s, z/ /s,z/ [ç, ʝ ] Velar fricative for /s,z,ʃ/: /s/ [x] Velarized tip alveolar sonorant or nasal /l/ [ʟ] /n/ [ŋ]. And one additional compensatory maneuver: ingressive air flow to build oral pressure (may be heard on any or all of the high pressure consonants stops, fricatives, affricates) 41 42 Repaired cleft palate & [ʔ] s (also NE and pharyngeal stop for [k] Repaired CPO with [ʢ] s for /s/ 43 44 J. Trost-Cardamone, PhD - CCC/SLP 11

Like any other child, children with cleft palate may also have Developmental speech errors Language problems Laryngeal (voice) problems (nodules) secondary to VP Insufficiency Obligatory speech errors due to dental and occlusal deviations Orofacial exam findings related to cleft palate speech characteristics Orofacial exam findings can inform us concerning oral structural underpinnings of the speech sound deviations we hear (For more guidelines on the orofacial exam, and structural Problems related to speech, see Appendix 2) 45 Normal oral structures Hard Palate and Alveolus Look for: Fistula[s] Size, location, patency/openness Common sites: alveolar/nasolabial Palatal [anterior, mid, posterior] Lowered palatal vault SMCP Taken From Peterson-Falzone et al. (2009) 47 48 J. Trost-Cardamone, PhD - CCC/SLP 12

Fistulas: sources for nasal air escape/ emission on pressure consonants More hard palate fistulas Taken from Peterson-Falzone, et al. (2009) 49 50 Nasolabial fistula Question: Why is it important to assess speech with a fistula occluded and unoccluded? (aka cul-de-sac testing) (think about the answer to this) Taken from Peterson-Falzone, et al. (2009) 51 J. Trost-Cardamone, PhD - CCC/SLP 13

Submucous cleft palate (SMCP) SMCP- with all the signs! Three (3) classical signs Bifid uvula. Whitish/bluish midline pale zone (zona pellucida) Palpable midline notch in posterior border of hard palate All signs are not always present Sometimes there are no visible signs 53 54 SMCP: a variety of looks 55 Velum and Uvula Velum: Length Symmetry Repaired Note: we cannot see VP closure on intraoral exam Uvula Repaired? Bifid? Missing? Fistula? 56 J. Trost-Cardamone, PhD - CCC/SLP 14

Uvula: look carefully Palatine tonsils: Are they obstructive? Consider position, size, and potential role in resonance and airway problems Large tonsils can cause VP insufficiency by growing up and behind velum and being obstructive to closure 57 58 Tonsils!! Adenoid Cannot observe adenoid intraorally Always get history information Still present? Snoring? Adenoid can help OR hinder VP closure 59 60 J. Trost-Cardamone, PhD - CCC/SLP 15

VP closure adult versus child Dentition: Dental deviations [deviations in specific teeth] Velopharyngeal closure in adult Veloadenoidal closure in child up until puberty/ adenoid resorption, involution This has implications for evaluating the adequacy of VP closure in kids with large adenoid and operated palates Missing teeth Ectopic teeth Rotated teeth Supernumerary or duplicated teeth 61 62 Ectopic lateral incisors Ectopic teeth 63 Occlusion: Occlusal deviations [how upper and lower jaws occlude] Overjet: protrusive premaxilla with or without Angle Class II malocclusion Underjet/underbite: with or without Angle class III malocclusion Maxillary deficiency/pseudo Class III Open bite: can be anterior or lateral Buccal/lateral crossbite Common on cleft side, secondary to maxillary collapse 64 J. Trost-Cardamone, PhD - CCC/SLP 16

Class III/ crossbite malocclusion Dental AND Occlusal problems Dental deviations include Lingually tipped central incisors Missing teeth in cleft area open bite Missing teeth in area of cleft open bite Rotated teeth Right maxillary arch collapse 65 66 Tongue: structural deviations Be thinking about the impact of dental and occlusal deviations on consonant production Size [evaluate relative size] Macroglossia (Beckwith Weidemann syndrome) Microglossia (Goldenhar, Hemifacial microsomia, Robin sequence) Ankyloglossia ( tongue tie ) 67 68 J. Trost-Cardamone, PhD - CCC/SLP 17

Microglossia Ankyloglossia: tongue tie Cause of bilateral collapse in mandibular arch Removal of molding force of tongue on dental arch Causes: Frenum can be Too short Attached too far anteriorly Attached too broadly on inferior surface Combinations Look for associated mobility/rom problems 69 70 Ankyloglossia: tongue tie Ankyloglossia: tongue tie 71 72 J. Trost-Cardamone, PhD - CCC/SLP 18

Ankyloglossia - protrusion Orofacial exam tools Don t be afraid to look and feel! 73 74 Recommended Speech Sampling Contexts (appropriate for Age 4 and older) Assessing for Cleft Palate Speech Errors Conversational speech Special sampling contexts for assessing for cleft type errors Other connected speech 75 76 J. Trost-Cardamone, PhD - CCC/SLP 19

UPS: Single Word Examples (pre-publication copy) See guidelines for constructing speech sample in Henningsson et al., 2008 77 78 UPS: sentence and phrase examples (pre-publication copy) High Pressure consonants /p/ Puppy will pull a rope /θ/ Thirty teeth /b/ Buy baby a bib /dʒ/ George saw Gigi Nasal consonants /m/ Mom n Amy are home /m,n,ŋ/ We ran a long mile Low pressure consonants /w/ We were away /l, r/ Laura wore a yellow lilly Zoo Passage Look at this book with us. It s a story about a zoo. That is where bears go. Today it s very cold out of doors, but we see a cloud overhead that s a pretty white fluffy shape. We hear that straw covers the floor of cages to keep the chill away; yet a deer walks through the trees with her head high. They feed seeds to birds so they re able to fly. Fletcher, SG. Contingencies for bioelectric modification of nasality. Journal of Speech and Hearing Disorders, 37, 329-346, 1972. 79 80 J. Trost-Cardamone, PhD - CCC/SLP 20

Special Sampling Contexts, cont CV syllables (ordered by place, front back) Single production [pʌ], [θ], [fʌ], [tʌ], [sʌ], etc# Serial/repeated productions [pʌ pʌ pʌ], [tʌ tʌ tʌ]...# Serial counting 60-66; 50-56; for distinguishing PSNE High vowels Isolation [u], [i]: resonance shift/cul-de-sac testing (High) vowels in words & sentences : for hypernasality Words with nasal consonants (eg, moon, name, etc) For hyponasality Speech sampling contexts some connected speech options (when conversational speech & sentences are limited) Picture description e.g., WAB picture, children s picture books Automatic speech e.g., counting 1-10, days of the week Memorized material ABC s, nursery rhymes, songs Pledge of Allegiance or other culturespecific material 81 82 Picture from the WAB Resonance Assessment-focus on hypernasality In connected speech, Is there any HN? Is it pervasive, intermittent? How does it affect speech understandability? Severity rating: there are many scales 4 point scale [0-3] 5 point scale [1-5] Other scales: as many as 11 points [See Appendix 5 for links to hypernasal speech samples] 83 84 J. Trost-Cardamone, PhD - CCC/SLP 21

Rating scale for hypernasality* 0 = WNL/adequate for regional speech 1 = mild 2 = moderate 3 = severe * See Henningsson et al. (2008) for descriptors for scale values Audible nasal emission: Is it obligatory or learned? Obligatory: due to VP insufficiency or fistula; true physical basis Location of fistula is important Learned: child/speaker directs air through the nose even when VP closure is physically possible 85 86 Phoneme-specific nasal emission (PSNE) Distinctive form of learned nasal emission May occur in children who never had a cleft or other form of VP inadequacy Also in children with repaired and physically adequate closure Only cure is speech therapy PSNE: how to identify it? Nasal emission that is selective Affects sibilant fricatives + affricates /s, z, ʃ, tʃ, dʒ/ Other high pressure consonants are WNL, demonstrating physiologically adequate velopharyngeal closure ability Negligible or no hypernasality 87 88 J. Trost-Cardamone, PhD - CCC/SLP 22

PSNE 89 Assessment: audible nasal emission & oral pressures Present or absent; no severity rating If present: audible or inaudible Nasal grimacing Listen for posterior nasal frication/ snorting Sustained vs repeated HPCs Nares occluded/unoccluded (cul-de-sac test) May help distinguish obligatory vs learned NAE Weak pressure consonants 90 Airflow & Air Pressure Assessment nasal air emission Low tech tools for detecting (inaudible) or confirming (audible) NE Presence and pattern of NAE: In single word articulation testing In connected speech using age appropriate tasks [nursery rhymes, sentence imitation, oral reading, conversation/spontaneous speech] Distinguish between potential sources of NAE Constant/pervasive: VP problem Due to fistula: relates to place of production Phoneme specific: learned Persists post-op: learned 91 92 J. Trost-Cardamone, PhD - CCC/SLP 23

Monitoring for nasal air emission reflector paddle Anterior oronasal fistula 93 94 PSNE See Appendix 4 for resources for ordering low tech materials for airflow monitoring 95 96 J. Trost-Cardamone, PhD - CCC/SLP 24

Identifying CMA induced VPI/A Production of CMAs can cause VPI/A even when VP port is physiologically adequate See References, Henningsson & Isberg articles Cleft palate speaker may achieve closure for HPCs made in correct place of production, but fail to achieve closure when substituting glottal stops or pharyngeal fricatives Instrumental imaging essential to confirm diagnosis This problem is correctable with speech therapy Repaired CLP with pharyngeal flap and [ʔ] s 97 98 Summarizing Consonant Errors/CMAs Types of errors present Sounds which they replace To give some idea of the error pattern e.g., glottal stops for all of the stops, pharyngeal fricatives for /s, z/ Stimulability Can they make the correct target with auditory,visual modeling and/or phonetic placement instruction? What speech therapy can treat and what it can t Learned (compensatory) articulation errors and learned nasal emission: YES!! Physically-based hypernasality, and other obligatory errors: NO!! e.g., Moderate/more than mild HN (+ nasal grimace) NE due to fistula(s) Artic. errors due to dental, occlusal and other oral structural causes of speech distortions 99 100 J. Trost-Cardamone, PhD - CCC/SLP 25

Making speech recommendations Based on your speech findings, what is your diagnostic hunch regarding VP function status? Adequate Inadequate and why/what you suspect to be the cause Can the speech problem(s) be treated with speech therapy? If the child has a cleft, is s/he under team care? If so, request recent team reports Collaborate with team SLP Does the child need a referral for team care? Has hypernasal speech, but no cleft You need help in JTrost-Cardamone, dignosing PhD-CCC/SLP and planning treatment 101 Finding a CLP or CF Team teams are located throughout the country most often in hospitals/medical centers finding the closest team? Contact the Cleft Palate Foundation (CPF), the educational arm of the ACPA (See website in Selected References) convenient, but not necessary, for team to be close to patient's home semi-annual to annual visits with ongoing care provided by community professionals 102 103 Making referrals Community physicians often are uniformed regarding cleft lip and palate, especially when there is not obvious cleft Children with hypernasal speech and no physical evidence of a cleft are best referred to a CLP/CF team Contact team SLP to discuss the case and get information on how to refer, financial assistance etc. Contact team coordinator, if no SLP name is available 104 J. Trost-Cardamone, PhD - CCC/SLP 26

Appendix 1 - Modified ExtIPA Chart Appendix material follows this slide 105 106 Appendix 2 Appendix 3 Taken from : Peterson-Falzone, et al., 2006 Taken from : Peterson-Falzone, et al., 2006 107 108 J. Trost-Cardamone, PhD - CCC/SLP 27

Appendix 5 Appendix 4 Airflow materials resources Videonasendoscopies of hypernasal speakers very short clips http://homepage.mac.com/changcy/voicenasal.htm Also listen to samples on the ACPA Website http://www.acpa-cpf.org then click on Health Care Professionals, then Education and Meetings, then Education (upper right), then "go to links" (of Speech Samples...), and then click on to the sample you want to hear. There are 3 groups of samples (child, female adult, male adult). The first sample in each group is a speaker with normal resonance. 109 J. Trost-Cardamone, PhD - CCC/SLP 28

Craniofacial Speech Disorders Annual ASHA Convention Judith Trost-Cardamone, PhD New Orleans, LA - Nov.21, 2009 Selected References American Cleft Palate Association (ACPA) and Cleft Palate foundation (CPF) Website: www.acpa-cpf.org CPF Hotline: 1-800-24-CLEFT Publication available for free download: Team care documents about teams and parameters for care: http://www.acpa-cpf.org/teamcare/ Henningsson GE and Isberg AM. (1986). Velopharyngeal movement patterns in patients alternating between oral and glottal articulation: a clinical and cineradiographical study. Cleft Palate-Craniofacial Journal, 23, 1-9. Henningsson GE and Isberg AM. (1991). A cineradiographic study of velopharyngeal movements for deviant versus non-deviant articulation. Cleft Palate- Craniofacial Journal, 28, 115-117. Henningsson G, Kuehn DP, Sell D, Sweeney T, Trost-Cardamone JE, Whitehill TL. (2008). Universal parameters for reporting speech outcomes in individuals with cleft palate. Cleft Palate-Craniofacial Journal, 45, 1-17. Kummer AW, Editor & Contributing Author (2008). Cleft palate and craniofacial anomalies. 2 nd Edition. Moller K and Glaze L (Eds). (2009). Cleft palate interdisciplinary issues and treatment, For clinicians by clinicians. 2 nd edition. Austin, TX: Pro-Ed. Peterson-Falzone SJ, Trost-Cardamone JE, Karnell MP and Hardin Jones MA. (2006). The clinician s guide to treating cleft palate speech. St. Louis: Elsevier. Peterson-Falzone SJ, Jones MA. and Karnell MP (2009). Cleft palate speech. 4 th edition. St. Louis: Elsevier. Trost-cardamone JE. (2004). Diagnosis of specific cleft palate speech error patterns for planning therapy or physical management needs. In KR Bzoch (Ed.), Communicative disorders related to cleft lip and palate. 4 th edition. (pp. 137-173). Boston: Little, Brown and Co. Trost-Cardamone JE. (1989). Coming to terms with VPI. Cleft Palate-Craniofacial Journal 27: 68-70. Trost-Cardamone JE. (1981). Articulatory additions to the classical description of the speech of persons with cleft palate. Cleft Palate-Craniofacial Journal, 18: 193-201. Trost-Cardamone JE. (1987). Cleft palate misarticulations: A teaching video. California State University at Northridge. (Provides descriptions of articulatory gestures, animations and audio samples of misarticulations).