Velopharyngeal Insufficiency Cleft Palate

The Normal Palate The palate extends from your teeth all the way back to the the uvula. It's purpose is to separate the nose from the mouth. Within speech, it prevents air from blowing out of your nose instead of your mouth. The palate is also very important when eating.

The Palate and Eating It prevents food and liquids from going up into the nose. During swallowing, the tongue presses up against the palate and pushes the chewed food to the back of the throat where it then goes down into the stomach.

Palate Development The prominences grow and come together, fusing to create the nose, the mouth, the lips and the front part of the palate. Next to the prominences are the palatine shelves which start out as ledges on either side of the mouth. As the fetus grows, these ledges lengthen and join in the middle to form the back of the palate in the same way that a zipper closes. The joining process, or "closing of the zipper" starts anteriorly and finishes posteriorly at the uvula. If the process of growth and joining is interrupted at any stage, a gap or split will develop, resulting in a cleft of either the lip or of the palate. The type of cleft that develops in the lip and/or palate depends upon when the joining process is interrupted.

Cleft Lip and Palate A cleft lip and palate occur when a baby is born with an opening in the hard and/or soft palate and the upper lip does not fully form. These conditions can occur separately so that some children are born with a cleft lip but a normal palate, and some have a cleft palate but a normal upper lip.

Prevalence Cleft lip and palate occurs in one out of every 500 to 1000 babies. It is one of the most common birth defects. Doctors and scientists know how cleft palates form, but they still do not have a complete explanation for why clefts occur, or what causes them.

Possible Etiology The most likely cause of clefting in an infant is a combination of: 1) The child's inherited traits 2) The environment within the mother's womb during pregnancy. In some way, the growth and development of the face are disrupted, resulting in a cleft.

Children born with a cleft palate have surgery at 7-18 months of age

Surgery

Major Goals of Surgery 1.Close the gap or hole between the roof of the mouth and the nose. 2.Reconnect the muscles that normally make the palate work. 3.Make the repaired palate long enough so that when the muscles are working, the palate can perform its function properly.

The major potential problems following surgery include: Breathing difficulty due to swelling in the mouth Bleeding Early or late separation of the repaired palate Infection Scarring Often, the child will be admitted to the intensive care unit immediately following surgery for closer observation.

Scar tissue It may take several months to form. Once present, the scar tissue may prevent the palate muscles from working properly, Or it may cause the palate to become too short to close off the passageway from the mouth to the nose.

Post Palate Repair Most children will immediately have an easier time in swallowing food and liquids. Part of the repair will split, causing a new hole to form between the nose and mouth in about 1 out of every 5 children following cleft palate repair.

Primary Goal of Therapy The primary goal is to prevent, reduce, or eliminate compensatory articulation. Compensatory articulation errors within this population includes glottal stops and pharyngeal fricatives which develop as a direct result of VPI. Therapy is not intended to reduce VPI, although in some children improved velopharyngeal function may spontaneously occur as articulation improves.

Eliminating Glottal Stops 1.Teach the child to replace glottal stops with the /h/ phoneme in order to break the child's habitual use of them. 2.Then the child should be taught the correct place of articulation. 3.Place of articulation should be more important than manner at the early stage. 4.If hypernasal resonance or nasal emission occurs, the clinician should use manual nasal occlusion, to help the child learn what it feels like to produce the sound with oral airflow.

Replacing Glottal Stops Play with “hhhh” aspiration, whisper while laughing Say “shhhhh” while occluding the nose Teach pressure consonants by following consonants with /h/ (e.g. “phhhhhop” for “pop”)

Eliminating Glottal Stops Teach place of articulation for oral consonants from nasals. Teach /n/ as place model for /d/ or /t/ Teach /m/ as place model for /b/ or /p/ Teach [ng] as place model for /g/ or /k/

Direct Therapy Stressed syllables encourage consonant production Velar consonants are encouraged within the final positions of words (talk) and when followed by a back vowel (good) Alveolar consonants are encouraged preceding a front vowel (tea)

Early Intervention-First Words Words to teach before palate repair: hello, hi, hey, honey, mommy, me, no, and wow Words to teach after palate repair: baby, boy, barney, pop, Pooh, toy, doll cookie

Non-Speech Activities Although blowing is a non-speech activity, it may be useful to help the child learn and experience what oral airflow feels like. Blowing however is not considered useful for teaching improved velopharyngeal closure for speech. "Raspberries" or "pa" repetitions are closer approximations to speech and are therefore preferable to blowing for practicing orally directed airflow.

Indirect Therapy Indirect Therapy-Parental Counseling Educate parents about normal language and sound development as well as effects of clefting on speech Teach parents the difference between oral and compensatory articulation

Parent Education Avoid reinforcing (repeating) compensatory articulation behaviors Encourage vocabulary expansion Encourage babbling games to stimulate stops Use manual nasal obstruction to provide the sensation of pressure buildup SLP should model methods of stimulation

Later Intervention Auditory Monitoring Speech Recordings –Analog –Digital Direct Auditory Feedback - Pick up sound at nose. –Stethoscope (toy versions work) –Tubes with headphones –Electronic Headphones

Later Intervention Cont. Monitoring Nasal Airflow/Acoustics –Nasal Mirror - may require two mirrors to facilitate patient viewing. –See Scape - (Pro-Ed Shoal Creek Boulevard, Austin, TX 78757, –Nasal tube to water. –Nasometer

Resources h/Instruction/new_speech_therapy/vpi_st_01.ht mlhttp://craniofacialcenter.uiowa.edu:88/speechpat h/Instruction/new_speech_therapy/vpi_st_01.ht ml Palate.htmhttp:// Palate.htm cation/PalateQT.cfmhttp:// cation/PalateQT.cfm %20and%20risk%20factors.htmhttp://hsc.virginia.edu/cmc/tutorials/cleft/causes %20and%20risk%20factors.htm