MA
Assessment and
Treatment
Aynsley Brian, Brittany Garay, Caroline
Johnson, Sarah Williams and Melissa
Gutierrez
Assessment
• Periodic assessments
are needed due to the
different times in
development that a
child with a cleft can
experience
communication issues.
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All children with a history of a
cleft or craniofacial are at risk
for communication disorders
Risk for communication
disorders for a child with cleft
of the primary palate is due
to dental abnormalities. Cleft
of the secondary palate puts
the child at risk for the
possibility of a fluctuation of
hearing loss and VP
dysfunction. These factors
can cause problems in the
areas of articulation,
language, phonation and
resonance at different times
in development.
Continuing Assessments
• Perceptual and
instrumental measures
should be done prior to
surgery to aid in
improvement of
speech and resonance
afterwards.
• A post-op assessment
should be done to
determine the effect of
surgery on speech and
possible further need
for intervention.
• Annual screenings with
the craniofacial team is
conducted until 4 years
of age.
• The child should
receive a speechlanguage evaluation
around age 3.
Diagnostic Interview
• Parent and family
interview
• If possible, obtain
information prior to the
interview about the
child’s medical and
developmental history
and parent’s current
concerns about
speech.
Possible Questions
• Was your child quiet,
average, or very vocal
as an infant?
• Does your child have
any difficulty chewing,
sucking, or swallowing?
• Does your child snore
at night?
• Has your child ever had
a speech evaluation or
speech therapy?
• What concerns you
about your child’s
speech?
• What sounds does your
child currently use?
• Does your child sound
nasal to you?
• How does your child
communicate?
• Was your child born
with any congenital
problems?
Language Screening
• Observe the child and
make note of their play
behaviors, ability to
request, follow
commands, their
spontaneous speech
production, and
repetition.
• Done throughout
preschool years
• Done yearly at cleft
palate team visits
• Can be done via
parent questionnaire
Speech Evaluation
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Formal articulation Tests
Templin-Darley Tests of Articulation
Bzoch Error Pattern Diagnostic Articulation Test
Iowa Pressure Articulation test
o Designed for assessing VP function
o Tests are easy to use, however only assess children at the single word level
Informal Articulation
Assessment
• Informal assessment of the child’s articulation at the
sentence level provides better information about
the child’s current functioning.
• Informal articulation assessment measures include
syllable repetition and sentence repetition. Samples
should contain many pressure sensitive consonants
that are voiceless.
• To assess hypernasality, the sample should contain
voiced oral sounds.
• To assess hyponasality, sentences should contain
high frequency of nasal phonemes.
Assessing in connected
speech
• Counting and rote speech could be used with
children. Assessing the child during connected
speech could be difficult, so have the child count
or recite the alphabet.
• Hypernasality, articulation errors and nasal emissions
are more apparent in connected speech.
What to evaluate?
• Articulation- important to identify the type and
potential cause of errors and types of
compensatory errors if present.
o Stimulability- is the child stimulable to correct erred sound by merely
changing placement? If so, this is a good prognostic factor for correction
with speech therapy.
o Nasal air emission- if present, determine the intensity, if there’s a rustle due
to opening, or if a grimace is accompanied.
o Consistency- how consistent are the errors or emissions.
What to evaluate?
• Phonation
o Types and severity of dysphonia
• Oral motor dysfunction
o Is apraxia of speech present? If so, should cause errors in valve closing
for oral sounds.
• Resonance
o Note whether normal, hyper, hypo, denasal, cul-de-sec or mixed
o Determine type and severity
Low and no-tech evaluation
procedures
Visual Detection
• Mirror test:
o Mirror held under nose in order to evaluate nasal air emission
• Air paddle
o Piece of paper is placed under the nose during speech tasks to determine
if nasal air emission is present
• See scape
o Nasal olive is placed in the child’s nose and is attached to a flexible tube
that’s connected to a rigid vertical tube.
o As the child repeats pressure-sensitive phonemes, a styrofoam stopper
rises in the tube is there’s nasal emission.
Tactile detection
• Feeling the sides of the nose
o Vibration can be felt from hypernasality
Auditory detection
• Nose pinch (cul-de-sac)
o Done by having the child produce speech with nose occluded and
unconcluded.
o In normal speech, no difference in quality should be heard.
• Stethoscope
o Drum of the stethoscope should be placed on either side of the nose.
o Hypernasality can easily be heard through the stethoscope.
• Straw
o Place one end of the straw in the child’s nose and the other end near the
examiners ear
o Can hear nasal emission
• Listening tube
o A plastic tube that works like the straw and stethoscope
o One end is placed in the nose and the other near the examiners ear to
assess nasal emission
Differential Diagnosis
• Hypernasality and air emission can be caused by
VPI, nasal fistula or articulation disorder
• Important to know the cause since it can have a
direct impact on treatment recommendations
o If oronasal fistula is present:
• Size and position can effect speech
• Compare anterior vs posterior sounds to determine if it’s symptomatic
• Close the fistula and compare occluded with unoccluded speech
• If hypernasality or nasal air emission is present, it’s
important to determine if it’s cause is structural or
due to misarticulation
o Is it due to a nasal rustle?
o Is it phoneme specific?
o Is the child stimulable?
Follow-up
• Recommendations:
o Treatment recommendations may be surgical, prosthetic management,
or speech therapy
o Discuss results with primary physician
o Should be based on cause, severity, and type of disorder.
• Family counseling
o Important outcome of the evaluation
o Give handouts on useful information
• Evaluation report
o Must be accurate, succinct, clear and concise
MA Recap
• 8 year old, 1st grade student in regular classroom
• DiGeorge syndrome and Pierre Robin Sequalae
• Tracheomalacia
o Tracheostomy tube secondary to tracheomalacia
o 2 decannulations unsuccessful due to cyanotic
• Complete bilateral cleft – repaired at 12 months
o Sucking and feeding problems
• Fed via Mickey tube until age 6
• Expressive language: apraxia, severe nasality and
past use of AAC device
Compensatory Errors with Pierre
Robin
• Misarticulations that occur as response to velopharyngeal
dysfunction
• Generalized backing
• Velar fricative
• Nasalization of oral consonants and vowels
• Nasal sniff and snort
• Pharyngeal plosive, fricative, affricate and nasal fricative
• Glottal stop
• Usually treated with speech therapy
Obligatory Errors with
Pierre Robin
• Obligatory productions occur when articulation
placement is normal but abnormal
anatomy/physiology causes speech distortion
• Short utterance length
• Weak or omitted consonant sounds
• Changed rate and speech segment durations
• Nasalization of oral sound
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Requires surgical or prosthetic intervention for
correction
Eliminating Misarticulations with
Speech Therapy
• Educate child on anatomy and articulator
placement
• Feedback
o Visual: diagrams
o Tactile: tongue blade, peanut butter
o Auditory: contrasting nasal and non-nasal, Oral-Nasal Listener (or straw)
Eliminating Misarticulations with
Speech Therapy
• Begin by training front sounds
• Plosives: bilabials and linguavelars
• Feedback:
o Visual: mirror, yawn technique (to push the tongue down and the velum
up)
o Tactile: tongue blade
o Auditory: open and close nose to contrast nasality
Eliminating Misarticulations through
Speech Therapy
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Pharyngeal plosive substitutions
Start with /ng/ and transition to /k,g/
Coordination of air pressure/release
Feedback:
o Tactile: spoon or tongue blade to suppress tongue tip, palpating throat
Eliminating Misarticulations through
Speech Therapy
• Pharyngeal fricatives and affricates
• Feedback
o Auditory: Straw (listening for airflow), alternate occluding nostrils
• Linguavelars (/t,d,n/)
• Feedback:
o Tactile: biting tongue blade between incisors
Childhood Apraxia of Speech (CAS)
• Makes inconsistent sound errors
• Can understand language much better than he or she
can talk
• Is hard to understand, especially for an unfamiliar listener
• Has difficulty imitating speech
• May appear to be groping when attempting to produce
sounds or to coordinate the lips, tongue, and jaw for
purposeful movement
• Has more difficulty saying longer words or phrases than
shorter ones
• Speech may be affected by situational anxiety
• Sounds choppy, monotonous, or stresses the wrong
syllable or word
Speech Therapy for CAS
• The focus of intervention for CAS is on improving the
planning, sequencing, and coordination of muscle
movements for speech production.
• Prosody training
• Imitate words and sentences of increasing length
• Getting feedback from a number of senses, such as
tactile and visual cues (e.g., watching him/herself in
the mirror) as well as auditory feedback
• Home exercise programs for maximum stimulation
Speech therapy for
hypernasality and nasal
emission
• Effective when the nasality is due to misarticulations
• Exception: residual hypernasality and/or nasal
emission after VPI surgery and, occasionally
hypernasality secondary to dysarthria
• Therapy techniques are the same for hypernasality
and nasal emission.
Low-tech auditory feedback
tools for hypernasality/ nasal
emission
• Straw
o Place 1 end at the entrance of the child’s nostril and the other end in his
ear.
• Listening Tube
o Used the same way as the straw
• Oral & Nasal Listener
o A dual stethoscope with the end of a tube placed in the child’s nostril OR
a funnel added to the end of the tube and placed in front of the child’s
mouth
Low-tech visual feedback
tools for hypernasality/ nasal
emission cont’d
• Air Paddle
o Paper paddle placed in front of mouth while producing pressure-sensitive
phonemes with enough air pressure to force the air paddle to move
• See-Scape
o While producing pressure-sensitive consonants, nasal olive placed in nostril
that is attached to a flexible tube which is connected to a rigid plastic
vertical tube containing a Styrofoam float
High-tech auditory feedback
tools for hypernasality/ nasal
emission
• Digital Recording Equipment
o Audio recordings of normal and hypernasal speech used to help
discriminate and self-evaluate
High-tech visual feedback
tools for hypernasality/ nasal
emission
• Nasometer
o Reads sentences, aiming to keep nasality below the clinician-set
threshold.
• Pressure-Flow Instrumentation
o Pressure-flow is recorded to correct articulation errors that cause
phoneme-specific nasal air emission.
• Nasopharyngoscopy
o Allows direct visualization of the velopharyngeal movements in order to
develop a degree of active control over the movements for
opening/closing the valve
Tactile feedback for
hypernasality/ nasal
emission
• Raise velum up/down with tongue depressor while
producing vowel sounds
• Lightly touch side of nose and face to feel vibration
• Yawn so that the posterior tongue is depressed and
the velum is elevated in order to coarticulate the
yawn with vowels and anterior consonant sounds
Tactile feedback for
hypernasality/ nasal
emission cont’d
• Increase volume
• Increase anterior mouth opening
• Pinch nostrils in order to feel increase in oral airflow
and pressure
Phonation
• Dysphonia, impairment of any or one of the vocal
organs, is common among people with VPI or
craniofacial anomalies
• Characteristics of dysphonia:
Hoarseness
Breathiness
Glottal fry
Hard glottal attack
Inappropriate pitch level
Restricted pitch range
Displophonia (a condition where two sounds of a different pitch are
produce simultaneously)
o Inappropriate loudness
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Phonation
• Dysphonia in patients with cleft
palate most commonly due to:
o Increased respiratory and muscular effort
o Hyper-adduction of vocal folds while
attempting to close the velopharyngeal
valve
• The presence of dysphonia
often masks nasality, making
perceptual evaluation difficult
• Increased vocal effort may also
increase VP function and
decrease gap size for better
resonance
• Should also note:
o Quality of breath support
o Type of breathing pattern
o Ability to sustain phonation
MA
• History of tracheomalacia
(weakness/floppiness of the
tracheal walls)
• Underwent a tracheostomy and
used a tracheostomy tube for
respiration
• After attempts at decannulation,
MA became cyanotic and had
severe stridor (tracheotomy tube
was replaced).
Techniques for Therapy
• Biofeedback-calls attention to automatic or
unconscious physiological processes to manipulate
with conscious control
• See-Scape• Aerodynamics-pressure-flow instrumentation
o provides objective documentation of therapy progress
Phonation
• Pneumotachograph-real-time
feedback measures:
o Inspiratory volume
o Maximum phonation volume
• To isolate inadequate respiratory
support from velopharyngeal
dysfunction, the clinician may plug
the nostrils for one measurement then
open them for the other
• Prolongation of voiceless continuants
may also help discrimination between
respiratory and velopharyngeal
factors
Therapy Techniques
continued
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Voice hygiene recommendations
Inspiratory Muscle Training
Holding breath for a certain time
Phonating while pushing/pulling
Pitch glides up and down