Speech assessment in cleft patients

1. Speech assessment in cleft
patients

2. Causes
• VPD
• Fistula
• Nasal blockage
• Glottal stop substitution
• Compensatory articulation errors

3. For diagnosis of speech disorders of persons
with cleft:-
1. Perceptual speech assessment (gold
standard)
2. Non instrumental tests
3. instrumental assessment and
4. imaging

4. Terms
• Intelligibility: perceived amount of speech
(i.e., number of words) understood
• Resonance: the perceptual balance of oral and
nasal sound energy in speech.
• Hypernasality: perception of excessive nasal
sound energy in speech, typically on vowels,
glides (W, Y) and liquid sounds (L, R)
• Hyponasality: perception of decreased nasal
sound energy in speech, typically on nasal
sounds M, N

5. • Mixed resonance: combination of both
hypernasality and hyponasality perceived by a
listener
• Nasal emission: abnormal escape of airflow
through the nose during consonant production
(can be audible or inaudible). When audible-
nasal turbulence
• Compensatory articulation errors: a pattern of
producing sounds in a posterior place of the vocal
tract (pharynx or larynx), where pressure and
airflow can be “valved” prior to their escape to
the level of the velopharynx or oral cavity

6. • Glottal stop substitutions: produced by
adducting the vocal folds together and
abruptly releasing the pressure beneath to
create the sound of an oral pressure
consonant. Often used as a replacement
(substitution) for pressure consonants like P, B,
T, D, K, G
• Nasal substitutions: the active replacement of
oral sounds P, B, T, D with nasal sounds M, N

7. Perceptual speech evaluation
during a spontaneous speech sample,
conversation,and/or picture description tasks
assessment of
1. intelligibility,
2. resonance,
3. voice, and
4. articulation

8. • standardized articulation test

9. • Oral-only or nasal-only stimuli (e.g., Buy baby
a bib, Pet the puppy, Mama made muffins,
etc.) are also used to assess
1. resonance,
2. nasal emission (audible and inaudible), and
3. Pressure for consonants

12. • speech parameters rated with five or seven-
point equal-appearing interval scales (visual
analog scales).
• Audio or video recording of speech
examination
• Speech evaluations at least 3–6 months
postsurgery

13. Non instrumental tests

14. Non nasal consonants Nasal consonants

15. For palatal fistula Mirror test-
• repeat the syllables /papapa…./ and
/kakaka…./.
• mirror fogs during /p/ but not during /k/

16. Indirect measurements
• acoustic assessment of nasality and
aerodynamic testing

17. • Nasalance is an acoustic index of nasality
• correlate with perceptual judgments of
resonance
• Ratio of the nasal sound energy divided by the
sum of the oral plus nasal sound energy in the
speech signal
• range from 0 to 100%
• Nasometer (Kay Pentax)

19. Imaging
• Static radiographs
• Multiview videofluoroscopy
• Nasopharyngoscopy

20. Cephalometry

21. • at rest (quiet breathing) and during sustained
production of sounds, such as /u/ or /s/
• palatal length
• Velar stretch,
• tonsil and adenoid size

23. Multiview videofluoroscopy
• Barium contrast through nose
• motion fluoroscopy records movement of
velopharyngeal mechanism from multiple
angles
• radiation dose is higher

25. 1. Palatal length,
2. pharyngeal depth,
3. velopharyngeal gap size,
4. Tonsil and adenoid size
5. Velopharyngeal mechanism during
connected speech

26. Nasopharyngoscopy
FOL – incomplete closure vs complete closure of VP

27. • Lateral wall movement
• Soft palate movement and defects of the soft
palate
• Length, V-shaped deformity, lateral muscle
movement, closure of sphincter, bubbling

28. Management

29. Treatment for VPI
1. Behavioral Treatment
2. CPAP Treatment
3. Superiorly Based Posterior Pharyngeal Flap
4. Sphincter Pharyngoplasty
5. V-Y (Wardill-Kilner) veloplasty or a Furlow
surgical procedure
6. Prosthetic treatment
7. Posterior pharyngeal wall augmentation

32. Furlow double-opposing Z-palatoplasty
1. in patients with an unrepaired submucosal
cleft palate
2. undergone cleft palate repair without levator
reconstruction
3. small velopharyngeal gap and good velar
length

34. Posterior pharyngeal flap
1. large velopharyngeal gap, greater than about
4 mm,
2. the velum is not very mobile;
3. there is adequate lateral pharyngeal wall
movement

36. Sphincter pharyngoplasty
• the velopharyngeal gap is smaller (less than
about 4 mm)
• the velum moves fairly well but does not
contact the posterior pharyngeal wall
• lateral pharyngeal walls may not be very
mobile

38. Posterior pharyngeal wall
augmentation
• Augmentation pharyngoplasty, using both
autologous tissues and alloplastic materials
• in patients with good velar motion and
relatively small velopharyngeal gap size

39. • pedicled flap of posterior pharyngeal mucosa,
rolled upon itself and inset across the
posterior pharyngeal wall
• Cartilage
• Autologous fat
• Teflon
• Proplast and calcium hydroxyapatite.

40. Prosthetic treatment
• diagnosis of VPD is unclear based on
perceptual speech and/or imaging findings
• comorbid speech problems make it difficult to
determine if surgical intervention will result in
meaningful improvement in speech
• known neuromuscular or degenerative
condition
• medical contraindications to having surgery

42. Behavioral speech therapy approaches
• Age 6–8 years or older.
• Intact cognitive skills.
• Intact motor skills.
• Adequate attention span and maturity.
• Normal hearing and vision.
• Good self-monitoring or speech self-correction
skills.

43. • At least some accurate articulation skills
already in speech repertoire.
• Can demonstrates measurable change within
the first few sessions of therapy.
• At least inconsistent velopharyngeal closure
for speech

44. Speech therapy is most appropriate treatment
for
1. articulation errors, as surgery cannot change
lip and tongue placement for the production
of speech sounds
2. phoneme-specific nasal emission or
phoneme specific nasalization of sounds

45. CPAP Treatment
• the velopharyngeal gap is small (less than
about 2 mm
• velum moves fairly well
• Hypernasality is mild to moderate

46. Treatment for Glottal Stops
• Glottal stops can be heard clearly with words
containing non-nasal consonants, such as
kitty, baby, taco, tick-tock, chicks
• easier to eliminate initially than to treat
subsequently

47. • first exercise, Breaking the Glottal Stop Cycle
– focuses on directing airflow through mouth
instead of nose.
• Second set of exercises, Generalizing Correct
Production to Other Speech Sounds
– to help patient learn to produce non-nasal sounds
correctly by building on nasal sounds that he or
she can already produce

48. Breaking the Glottal Stop Cycle.
1. Have patient open the mouth and exhale or sigh
onto hand or mirror.
2. Have patient make a sustained /h/ sound.
3. Have patient make a sustained /h/ followed by a
sustained vowel such as /a/, thus hhhaaa.
4. Have the patient say aaahhhaaa (sustained /a/
followed by sustained /h/ followed by sustained
/a/).
5. Have the patient say hhhaaapaaa, making a light
/p/ contact

50. References
• Plastic surgery, Neligen 6th edn
• Current therapy in plastic surgery, McCarthy