VPD
Yusra
Gadeer
Compensatory Articulation (CA)
● Articulation impairments associated with the structural deviations due to a
velopharyngeal insufficiency.
● Learned articulation errors, they are errors in place of articulation or direction
of airflow. (ASHA)
● CA can also be considered a phonological disorder. These errors can
become apart of the developing rule system of articulation
Assessment
●
It is important to note that most often the errors are in the placement.
Manner and voicing are typically preserved.
● The errors are not distortions of oral phonemes, they are a substitution of a
different phoneme all together, which make speech unintelligible.
Symptoms
●
occur below the level of the VP port and eliminate the need for valving of airflow at the level of the
oral cavity and/or the VP port by using the pharynx or larynx to valve air or pressure (glottal stops
and fricatives [/h/])
●
occur in front of the VP port and involve backed place within the oral cavity (velarized alveolars
and palatals)
●
use the opening of the VP port as part of the articulation for intentional nasal release of airflow and
simultaneous bilabial, alveolar, or velar closure (realized as voiceless nasal fricatives)
●
involve ingressive rather than egressive airflow to eliminate the need for closure of the VP port
(e.g., bilabial smacks)
Treatment
Speech strategies are used according to the severity of the CA pattern (which is classified depending on
the frequency of its appearance during speech and the response to correction prompts).
1. patients who are able to produce a correct articulatory pattern only on isolated phonemes or short
words, with consistent prompting are more likely to show an effective response to direct instruction
on placement and manner of articulation. A possible explanation is that these patients show a
limited level of phonological awareness. (phonetic change, cloze procedure with phonemic cues,
and think aloud in phonemic awareness)
1. strategies, which use modeling and modeling with stress usually, seem to be effective in patients
with lower degrees of severity of CA. These patients appear to be more aware of the characteristics
of the speech sounds. Thus, they seem to be more confident for producing these sounds during a
more structured and complex discourse
Nasal Air Emission
●
Airflow deviation characterized by speech airflow and emission through the nose. nasal air emission
occurs when there is an attempt to build up intraoral air pressure for the production of consonants in
the presence of a leak in the system (velopharyngeal port or oronasal fistula). Some of the airflow is
released through the nose, causing a disruption in the aerodynamic process of speech. NAE is most
noted on pressure-sensitive phonemes (plosives, fricatives, affricates).
●
Learned nasal emission can be realized as nasal fricative substitutions or nasal emission that is
co-produced with the target sound and may be associated with nasal turbulence or snorting.
Nasal emission
• 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 and Inaudible Pressure
If nasal air emission is inaudible, then it can be detected visually by the /s/ mirror test or the nasal
emission test. The mirror test can also be conducted on other phonemes. While it is not obvious in
speech, it may be important diagnostically. Because voiceless consonants are associated with increased
oral air pressure, these are more often associated with nasal air emission.
If nasal air emission is audible, then air forced through the small opening causes friction and bubbling of
secretions(nasal rustle)/ nasal turbulence
Distortion is loud and distracting
•Has no effect on consonants or utterance length
Learned NAE Patterns
●
●
Phoneme-specific nasal emission (PSNE) — nasal emission that is limited to one or more specific sounds.
○ PSNE typically affects fricatives and may also affect affricates.
○ It may occur in individuals without cleft palate.
○ It is treated through behavioral intervention (i.e., traditional speech therapy).
Persisting postoperative nasal emission — nasal emission that continues after surgical repair of the cleft palate
when VP closure appears to be adequate.
○ The individual continues to use the pattern of directing air into the nasal cavity.
○ The clinician may need to consult with the team SLP to confirm adequate closure prior to behavioral
intervention.
Nasal Rustle Can be structural or functional
●
●
Structural Defect
■ Occurs inconsistently, but on all pressure sounds, including /p/, /t/ and /k/
Functional Error
■ Occurs consistently, but only on certain sibilants (i.e. s/z)
Assessment
To test hypernasality or nasal emission, use oral consonants with high and low vowels
1. Repetition of Syllables (pa, pa, pa, pa…pi, pi, pi, pi…/ ta, ta, ta, ta… ti, ti, ti, ti…/ka, ka, ka, ka… ki,
ki, ki, ki…sa, sa, sa, sa… si, si, si, si…/sha, sha, sha, sha…shi, shi, shi, shi…)
1. To test hyponasality, use nasal sounds with high and low vowels: (ma, ma, ma, ma… mi, mi,
mi, mi…/na, na, na, na… ni, ni, ni, ni…)
1. Utterance length should be tested if there is significant nasal emission. This can be done by having
the child count to 20 and noting if he has to take a breath in the middle
2. http://www.nchn.org.au/cleft/docs/VPI_screener.pdf
Low Tech or No Tech
1-Mirror test: ask the client to produce a long /s/ sound. Place the mirror under the nose. Fogging of the
mirror indicate nasal emission. It needs to be sure the mirror is placed after /s/ begins and removed prior to
/s/ ceasing to avoid fogging up with exhalation.
2-Air paddle: An air paddle can be cut from a piece of paper and placed underneath the nares during
speech. If the paddle moves during the production of pressure-sensitive sounds, this indicates that there is
nasal air emission.
3- See scape: Detects nasal emission of air during speech. When tip is placed in child’s nares, any
emission of air causes the float to rise in the rigid plastic tube. Instant visual feedback and an indication of
air-flow pressure and velopharyngeal incompetence. Tests air-flow pressure rather than nasality, which
indicates a lack of velopharyngeal competence perceived as hypernasality. It can be used for tx and home
practice.
Mixed resonance
When different types of resonance occur in combination at different times in
connected speech. For example, an individual with VPI would have predominantly
hypernasal speech, noticeable on vowels and maybe some oral consonants. If that
individual also had a partial blockage in the nasal cavity, then the nasal phonemes
may sound hyponasal.
What Are Weak Pressure Consonants?
The speech sounds that need the palate to close to the back of the throat are
called “pressure consonants”. In English, these include p, b, t, d, k, g f, v, s, z, sh,
ch, dg, th. A child who has an unrepaired cleft palate cannot build up the pressure
in the mouth to make these sounds.
What is Double Articulation?
refers to the twofold structure of the stream of speech, which can be primarily
divided into meaningful signs (like words or morphemes), and then secondarily
into distinctive elements (like letters or phonemes). For example, the meaningful
English word "cat" is composed of the sounds [k], [æ], and [t], which are
meaningless as separate individual sounds (and which can also be combined to
form the separate words "tack" and "act", with distinct meanings).
Other Surgeries for When The Child Gets Older?
1. Children whose cleft lips involve the alveolus, or gum line, typically need another operation to help
their permanent teeth come in and to make it easier for orthodontic treatments to improve their bite
and jaw function. This operation is called an alveolar bone graft, and is usually performed when the
child is 8 to 10 years old.
1. 5 to 15 percent of all children who have undergone a cleft palate repair will need a second operation
to correct “nasal”-sounding speech. The most common procedure used to fix this problem is called a
pharyngeal flap, which is performed when the child is about 5 years old
References
Prathanee, B., PhD, Pumnum, T., & Seepuaham, C. (2013). Types of Articulation Errors in Individuals with Cleft Lip and
Palate. J Med Assoc Thai, 96, 81-90. Retrieved July 3, 2019, from
https://pdfs.semanticscholar.org/db9d/5d5c12622ebdbcef5c9d953d47645587ecb4.pdf.
Del Carmen Pamplona, M., Ysunza, A., & Morales, S. (2014). Strategies for treating compensatory articulation in patients
with cleft palate. International journal of biomedical science : IJBS, 10(1), 43–51.
ASHA.com