Cleft Palate Speech-Part 2:
Assessment, Intervention and
Medical Referrals Related to the
School-Aged child With Cleft Palate
Jeff Steffen M.A., CCC-SLP
Manager, Foothills Speech and Language LLC
Children’s Hospital Colorado, Cleft Lip and Palate Team
Consultant
www.foothillsspeech.org
Structure Vs. Function
• The Bridge to Nowhere
Typical Surgical Timelines
The School Aged Child
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Lip and Nose Revision
P.E. Tubes
Secondary Management
Palate Repair Submucous
Bone Graft
La Fort I, II, III
Final rhinoplasty
Age 4-5
As needed
Age 4-6
Age 3-5
Age 8-10
Age 15+
Age 15+
Assessment of Structure and Function
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The head and face
The lip and nose
The Alveolar Ridge/anterior palate
The Mid Palate
The soft Palate
The Head and Face
Structure
• Visual alignment of parts
• Use a tongue blade
Function
•Facial and cranial Nerve Tests
•Symmetry of smile
•Lip strength
•Blink eyes
•Strength against resistance
•Lingual mobility
•Palate mobility
•Swallow
•Gag reflex
The Lip and Nose
Structure
Function
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Nasal symmetry
Septal deviation
Turbinate hypertrophy
Columella length
Lip symmetry
Labial frenulum
Lip rounding
Possible nasal obstruction
De-nasal resonance
Open mouth breathing
Forward tongue placement
Allergies
Interdental distortions
Hard to occlude nose
Poor lip rounding /w/, /r/
The Alveolar Ridge
Anterior Palate
Structure
• Lateral segment collapse
• Fistula (multiple)
• Tooth in palate
• Dental decay
Function
• Airflow distortion
• Poor lingual placement
• Nasal emission
• Mid-dorsal placement
• Obligatory errors
– Occlusion Class III
• Aberrant sounds (sucking
air through fistula)
Assessing Palatal Fistula
Does it effect velopharyngeal function?
Tools for Assessment
Temporary Obturator
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Make a “Mouth Pancake”
Use bilabial sounds and low pressure sounds
Re-test Nasal Emission
Perceptual changes on vowels
– Use listen tube
• Obturate or not?
Pros/cons
Surgical Closure of fistulae
Considerations
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Anterior fistula with bilateral lip/palate
Scaring and effects of future expansion
How symptomatic is it? (explain yourself)
Does size matter?
Tongue flap, etc.
The Mid Palate
Structure
• Fistula
– May not be able to obturate
• Arch height
• Scaring
Function
• Nasal Emission
• Mid dorsal stops
• Backing errors
• Food/liquid in palate
• Effect on resonating space
“The Crux of the Biscuit”
The Posterior Palate
Structure
• Short Palate
• Immobile Palate
• Incomplete resection of
Levator
• Dehiscence
• Fistula
• Tonsil/adenoid hypertrophy
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Function
Velopharyngeal Dysfunction
Velopharyngeal Insufficiency
Velopharyngeal Inadequacy
Velopharyngeal Incompetency
Neurologic component
Velar notching
Snoring/OSA
Assessment
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YOUR EARS!!!!!!!!!!!!!!!
Rating Scales
Nasometry
Nasopharyngoscopy
Videoflouroscopy
Still x-ray of “eeeee”
20% require secondary management
Rating Scales
Speech Scales
Treatment Vs. Medical Management
Treatment
The Speech Sample
Pepperoni Pizza
Pick up the puppy
Take a turtle to lunch
Daddy ate the Doughnuts
Daddy does the dishes
Chugga chugga choo choo
Find the funny fox
Go get cake and cookies
Susy slipped on the ice
Speech Sample
Low Pressure Sentences
Hi how are you?
Where are you?
I love you.
I have a yellow yoyo.
Oh wow.
Sustained vowels
Who’s Ready to Play?
• Conceptual awareness
• The right Timing
• Coaching versus Teaching
• Inspiring!!!
Conceptual Awareness
(For the Player)
Conceptual Awareness
(For the Parent)
Eliminating Errors
(Glottal Stops)
Start with Voiceless Stop /p/
• Whispered (use /h/ transition to vowel)
• After “ah”
• Puff checks out and press checks for short oral
release of air.
• Use listen tube
• Lip trill (horse sound)
• Use placement map
Or you can try
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Voiced /b/ but not as much tactile feedback
Especially if voicing errors occurring
Use in final position as air is moving already
Repeat final position to approximate medial
Move to whisper of initial vowel sound (uh)
• Once established much like articulation therapy.
Tricks of the Trade
• Use paper “snow” balls, cotton balls
– Position of mouth to paper important
• Reverse use of listen tube
• Cul-de-sac technique (pinch nose)
• Discrimination (auditory/production)
– Hand on throat to feel laryngeal elevation
Tricks of the Trade
• Use paper “snow” balls, cotton balls
– Position of mouth to paper important
• Reverse use of listen tube
• Cul-de-sac technique (pinch nose)
• Discrimination (auditory/production)
– Hand on throat to feel laryngeal elevation
Pharyngeal Stops
• Teach anterior placement first
– Can try the yawn technique (lowers tongue base)
• Velar placement
– /g/ often easier from –ng (Inga)
– Hold anterior tongue “in bed”
• The anti-nap technique for awareness
– Can try tongue blade to hold tongue down
– Push tongue back (gagging)
– Use mirror and/or video feed back
Pharyngeal Fricatives
• Release /t/ into an /s/ (don’t mention /s/)
• Use straw (McD’s or Starbucks)
• Determine if other phonemes affected
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/f/ (pinch nose)
Bite teeth (often too hard for air flow)
Pretzel sticks or liquorish ropes
Popsicle stick (slants downward)/air over top
• “sh”..hush sound
– Occlude nose
– Video clip of visual feedback
The Palatal /s/
• Teach awareness of posterior lateral blades of
tongue
• Biting/pressing tongue to maxillary incisors
• Straw across teeth at canines
• Mouth Space and the pink alien
– Mirror
– Good for frontal /s/ too
The Palatal /s/
• Teach awareness of posterior lateral blades of
tongue
• Biting/pressing tongue to maxillary incisors
• Straw across teeth at canines
• Mouth Space and the pink alien
– Mirror
– Good for frontal /s/ too
Phoneme Specific Nasal Emission
• Diagnose it first
– Sentence without /s/
– Compare to counting 60-70
• Teach awareness and discrimination
– Many of the /s/ techniques can be useful
• Use placement map
• Praat Software for older kids?
Hypernasal resonance
• Rarely does speech alone help
• Teaching correct function/articulation can
improve it.
• Over articulation techniques
• Slowing rate
• Possible motor coordination VP timing issue
• Oral/nasal contrast (be more hypernasal)
– Sound clip of congenital VPI
– Video clip of oral/nasal contrast
Praat (/s/ nasal fricative)
Praat (ba…mba)
Referring for Medical Management
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Determine if seen by a team
Get most recent report/follow up with rec’s
Refer to SLP for consultation/2nd opinion
Write update as to why management.
Jeff Steffen
www.foothillsspeech.org
jeff@foothillsspeech
Question self and others
Inspire !!!
Thank you (and enjoy)