Written for Prescription Parents. Dr. Miller can be reached at 46 Central Ave., Newton, MA 02160.
Other Internet Resources Related to Cleft Lip/Cleft Palate
The child who is born with a cleft of the palate brings special considerations relative to communication development owing to the presence of the cleft.
As speech and language pathologists, we are concerned with the total development of the child with regard to communication skills. For purposes of our discussion it may be helpful just to present an overview of speech and language development. When we talk about language we are talking about the symbol system which we all use to understand/make sense of the words which we are hearing (this is our auditory receptive system) and then to be able to formulate and speak with appropriate word usage and appropriate word order (our sentence structure -- our expressive language). Children by the age of one year have usually begun to say their first single words, and by the time they are 18 months of age they are generally using between five and ten words meaningfully and consistently, but may have as few as three and as many as fifty and still be considered within the norm. Children around 18 months also begin putting words together -- two-word phrases; by age two years they are using two and three-word phrases and have begun to learn the power of word order. By two and a half years children are using simple sentences, and by age three years language structure is relatively intact, with, however, of course, some expected immaturities relative to children's grammatical markers. By age four much of language structure has been refined to a more adult structure, though the process may take a few more years to be completed.
With regard to speech, we are talking about the motor component of our communication, and which requires intact structures of the lips, jaw, tongue, teeth, and palate, working in coordination with muscles of respiration and phonation. Indeed the four substructures of speech are respiration (our breathing), phonation (the sound that is made by the vocal folds), articulation (the production of sounds using the lips, teeth, tongue and jaw movements), and resonation (which is the quality of the voice regulated by the integrity and the movement of the soft palate and surrounding structures).
When we talk about the child with a cleft of the lip, with or without a cleft palate, we should note that for the purposes of the discussion of speech and resonance, for the most part children who are born with clefts of the lip only do not experience speech or resonance problems (related to clefting itself), unless for some reason the repair of the lip has resulted in a very tight and constricted musculature -- which is very rarely the case these days. The child who is born with a cleft of the palate (with or without a cleft of the lip) presents a problem initially simply because of the opening in the roof of the mouth which is preventing the soft palate to close off the space between the nasal cavity and the mouth cavity. Because of this, sounds which must come out directly through the mouth may be greatly distorted or impossible for the child to make. The current philosophy, therefore, is that surgical repair of the palate should be performed generally prior to or by one year of age (the time at which the child generally is beginning to say his or her first words). It should be noted here that the palate with the uvula hanging down is at rest for breathing and for the 'm,' 'n,' and 'ng' sounds. For all other sounds the palate stretches and raises and makes firm contact with the posterior pharyngeal wall (the back throat wall) -- above where we can see when we look in with the naked eye. At the same time this is occurring the side pharyngeal walls, or lateral pharyngeal walls, are moving in as well (also above where we can generally see with the naked eye), and the movement of the velo-pharyngeal mechanism is noted to be sphincteric. ('Velo' refers to velum or soft palate, and 'pharyngeal' refers to the back and side walls of the throat.)
The speech pathologist, as part of the management team, may see a child before surgical repair of the palate to counsel with parents and to provide them with activities to enhance oral movement and encourage vocalization. Shortly after the palate repair is completed the child may be seen for a complete assessment, at which time all of the parameters of communication development are assessed. This includes pre-speech and pre-language development, the number of sounds the child is making, the type of interaction and play behavior, the actual words or approximations which the child is attempting, and the sounds which the child is now capable of producing in any form. From the analysis that is derived we can begin to assess whether the child's velo-pharyngeal mechanism appears to be working adequately to close the nasal port from the mouth cavity in order to allow the child to make sounds of speech.
The development of the sounds of speech progress from the more simple gross sounds to more complex sounds (going from simple to more highly coordinated as with the development of other motor skills). Early developing sounds for all children appear to be 'm' and 'n' (which are nasal sounds) and 'b', 'd', and 'g' (plosive sounds). These plosive sounds are very important in our early analysis of children with repaired cleft of the palate in that the child must be able to have tight seal of the velo-pharyngeal mechanism and hold the air within the oral cavity and then release it forcefully. If there is difficulty with the appropriate valving of the velo-pharyngeal mechanism, there may be what is called nasalization of plosives, in that the sounds will go through the nose, with a 'b' produced as an 'm', a 'd' produced as an 'n', and a 'g' produced as an 'ng'. Should we hear this early on with a child, we would be concerned that the mechanism is not working appropriately. If the child appears to be using these sounds appropriately within his repetitive syllable and single word context, we would judge that at least at an early stage of development the mechanism appears to be working effectively. This of course does not preclude the possibility of some mild difficulties as more complex sounds emerge.
It is important to see the child on at least an annual basis through the first six to eight years of life to make certain that all is proceeding appropriately with regard to both speech and language. Many children master all the sounds of their speech at an early age, though it is not unusual to find that some children have difficulties with some later developing sounds until the age of seven. By eight years of age we will anticipate that children will have mastered all of their sounds, and certainly by the age of three we would expect that children, even with speech sound difficulties would be intelligible to most individuals. The way in which children master their sounds is that they first omit sounds that are too difficult. They then substitute the easier sound for their target sound (example: 'toap' for 'soap'); they then distort sounds so that the sound is almost but not quite right; and then the sounds are more and more refined until there is no distortion present. It is also important to note that children may have greater or lesser difficulties with the same sound, depending upon where it occurs in the word or what sound comes before or after it.
It is important to note at this time that there is a high prevalence of middle ear problems in children with clefts -- these usually will resolve as the child matures; however these have the potential for being very problematic relative to communication development owing to the frequency of occurrence in young children. All children with clefts of the palate are born with middle ear fluid, as opposed to thirty percent of the population without clefts. The way in which we learn to understand and to speak is primarily through our hearing mechanism, and if there is middle ear fluid hearing may be affected to a significant degree. We therefore always advise parents to be sensitive to any apparent lack of responsiveness to sound on the part of their children and to have any concerns relative to hearing evaluated promptly. Middle ear fluid does not always occur in the presence of an ear infection, and in children with clefts it may be of a very fluctuating nature. Medication or the insertion of ventilation tubes in the middle ear may be recommended for children with recurring middle ear problems.
I would like to return now to the issue of resonance and voice quality as they relate to sequelae of cleft of the palate. Some terms which are used specifically relative to speech considerations for the child with cleft palate are as follows: we talk about velo-pharyngeal competence, velo-pharyngeal sufficiency, or velo-pharyngeal adequacy as terms to describe the effective working of the velo-pharyngeal mechanism, in that the palate is long and mobile enough to effect a tight seal so that air does not escape into the nasal cavity (except for 'm', 'n', and 'ng'), but rather is directed out through the mouth.
In such a case the child's resonance would be said to be unremarkable, or normal. If the child's velo-pharyngeal mechanism is not working adequately the child is said to have velo-pharyngeal incompetence, or velo-pharyngeal insufficiency, or velo-pharyngeal inadequacy (you may see these terms used interchangeably). When this occurs, the child may have what we call hypernasality, which means that the air and sounds are coming through the nasal cavity at undesired times. Hypernasal resonance refers to the tone of the voice for voiced sounds. When a child is producing sounds that do not have tone to them, such as 'p', 't', 'k', 's', 'f', 'sh', 'ch', and air is observed on a mirror coming through the nostrils, the child is said to have nasal escape, or nasal emission. This can be silent (seen on a mirror but not heard), or it can be audible -- and can take various forms, with a great deal of turbulence noted at times. There are times when children who have velo-pharyngeal insufficiency or inadequacy attempt to try to compensate for being unable to effectively valve at the level of their velo-pharyngeal sphincter and try to prevent the air from going out through the nose. Some things that are seen may include trying to stop the air at the level where the sound is produced, the vocal folds, and this will produce what is called a glottal stop. Sometimes individuals will try to trap the air at the back of the throat, especially for sibilant sounds, such as the 's' and the 'sh', and produce what is called a pharyngeal fricative. Individuals may also engage in facial grimacing, again in an effort to prevent or modify the flow of air and sound through the nose instead of through the mouth. Individuals may hold their tongue in a backward and upward position in an effort to close off the space and try to effect velo-pharyngeal closure. There are a wide variety of other compensatory types of mannerisms and productions which may be seen in the child with velo-pharyngeal insufficiency or inadequacy in an attempt to compensate for ineffective valving.
Hopefully we will be able to identify early on, at least by the second or third birthday, if not before, those children who have velo-pharyngeal insufficiency or inadequacy which is significant enough so that the child may need a secondary surgical procedure in order to help them to have an appropriately working velo-pharyngeal mechanism. If a child is going to be in need of this, then it will be very important until such time as the surgery is performed to work with this child to help him or her to learn the correct placement for sounds so that when the palate is working appropriately he or she will not have to unlearn inappropriate compensatory productions for sounds. Another issue that is of concern to children with repaired cleft of the palate who may have some degree of velo-pharyngeal inadequacy or insufficiency is the use of overly tense and loud or soft and breathy voice quality, again possibly in an effort to compensate for not being able to close the nasal cavity from the oral cavity successfully during speech. This again is an area that requires and benefits from work with a speech pathologist.
If secondary surgery, which is usually a pharyngeal flap, is required, it will generally be done before the age of five or six in order to have the best speech results. It should be noted here that the speech pathologist's role in working with a child with problems related to velo-pharyngeal insufficiency is to foster appropriate placement for sounds, increase oral awareness, and anterior/oral tone focus, encourage forward tongue and tongue-tip placement, and enhance relaxed, unstrained voice production. However, speech therapy cannot correct velo-pharyngeal insufficiency or inadequacy; this is the role of the surgeon, or in cases where surgery is not appropriate because of medical or other considerations -- the prosthedontist.
Fortunately the state of the art is such that now, with the timing of surgery and the advancement of surgical techniques, the vast majority of children with repaired clefts of the palate present with appropriate speech and resonance, and do not require secondary surgical procedures. The important thing is to have the child followed early and on a consistent basis so that any problems with any aspects of communication and velo-pharyngeal dysfunction may be identified and remediated.
Addendum
If the speech pathologist feels that a child may be a candidate for consideration of a secondary procedure, a multiview speech videoflouroscopy may be requested to help the surgeon plan his surgery and also to determine the potential benefit that the child may derive from the surgery. Speech videoflouroscopy is a diagnostic procedure performed by the radiologist that is used to assess velo-pharyngeal competence/ adequacy/sufficiency -- which is the ability to completely seal the oral cavity from the nasal cavity during speech. Closure is really sphincteric and involves movement of the soft palate (the velum), the lateral (side) pharyngeal walls, and variably the posterior (back) pharyngeal wall. For this reason a multiview videoflouroscopy is essential. The lateral view assesses the length and movement of the soft palate and any forward movement of the posterior pharyngeal wall. Incomplete, marginal or complete approximations are noted. The frontal view assesses the degree and symmetry (even movement on either side) of the lateral pharyngeal wall movement. Normal excursion from the resting position is halfway towards midline -- though this is variable. The base view assesses the total sphincteric movement (of the velo-pharyngeal mechanism). Sounds, phrases and sentences are repeated during this study.
Nasendoscopy is another diagnostic procedure in which a tube (high optic fiber rod) is inserted into an anesthetized nose which gives a view of the palate and adjacent structures in motion from the top.
Other Internet Resources Related to Cleft Lip/Cleft Palate
Please visit our online store at http://store.yahoo.com/samizdat
Sitemap with links to every page at our site www.seltzerbooks.com/sitemap.html
<
| Internet Business Showcase: | ||
Hair Restoration for Hair Loss Hair Restoration |
Plastic Surgery & Surgeons Used Cars Guide |
Homecoming & Prom Dresses |