1. Craniofacial and VPI Related Speech Disorders
Melissa Montiel, SLP

2. Financial Disclosure
Financial Disclosure: I am receiving an honorarium from the South Carolina Speech Language Hearing Association for this presentation and is employed by MUSC.
Non Financial Disclosure: No relevant non- financial relationships to disclose.

3. What’s the difference?
Normal mechanism vs. Cleft

4. Mechanism differences (cleft palate)
Smaller “vault”
Possible malocclusion
Anterior “fistula” until bone grafting
Possible fistula from dehiscence

5. Smaller vault

6. Smaller Vault
Articulatory deficits

7. Malocclusion/Midface Hypoplasia

8. Malocclusion
Frontal sibilants (III)
Difficulty with bilabials (II)

9. Alveolar fistula

10. Alveolar fistula Nasal regurgitation Nasal air emissions
Palatal expander and speech

11. Dehiscence after repair

12. Dehiscence
Minor NAE
Nasal regurgitation

13. “Normal” vs Cleft related speech

14. Normal Errors Fronting, gliding, stopping
Treated based on “age-appropriate” standard norms
May or may not resolve without tx

15. Cleft Palate related disorders
Backing
Palatalizing
Compensatory: Glottal stopping, other (clicking)
Nasal Assimilance
VPI
Not likely to resolve without intervention
Goals not based on age/developmental norms

16. Backing
Producing phonemes as /k,g/ ex:
-Do=goo
-Two=koo
-boat=goat

17. Backing

18. Backing

19. Backing

20. Palatalizing Smaller vault, less space for tongue
Producing alveolar phonemes with mid-dorsal part of tongue vs tongue tip

21. palatalizing

22. Palatalizing

23. Glottal stopping Mechanisms way to produce pressure
Bypasses the VP mechanism on exam
Can be because of VPI, or could be learned
Very detrimental to intelligibility

24. Glottal Stopping

25. Glottal Stopping

26. Glottal stopping

27. Glottal Stopping

28. Glottal stopping

29. Compensatory
Deficits produced by child attempting to make correct sounds
Clicking, guttural sounds

30. Clicking

31. Compensatory- Clicking

32. Nasal Assimilation
Producing vowels with hypernasality or phonemes with NAE when they are in the presence of a nasal phoneme
-ham pizza, the /pi/ has NAE/hypernasality due the /m/ influence

33. Velopharyngeal insufficiency (VPI)
Velopharyngeal Insufficiency: results in “An anatomical or structural defect that precludes adequate velopharyngeal closure (the decoupling of the oral and nasal cavities) ”*
Basically, one is unable to appropriately and/or fully close off your oropharynx from the nasopharynx for the purpose of speech/swallowing

34. VPI
Hypernasality- Too much energy in the nasal cavity. (Rant about hypo vs hypernasality)
Nasal air emissions
Weak pressure consonants (m/b, n/d)
Nasal grimacing

35. VPI Poor feeding/sucking as infant
Trouble blowing out birthday candles
Difficulty drinking through a straw
Nasal regurgitation

36. Hypernasality vs NAE
Hypernasality is too much energy resonating in the nasal cavity.
Nasality describes energy. Vowels are energy. We are using the term hypernasal to describe a vowel.

37. NAE
Most consonants have pressure, so you are listening for a nasal air emission (NAE), which sounds like snorting
Can also perceive weak pressure on phonemes (m/b, n/d)

38. VPI

39. VPI

40. VPI

41. VPI

42. Time out: Phoneme specific Nasal Air Emission (PSNAE)

43. Phoneme specific Nasal air emissions (PSNAE)
Deficit in which the patient is able to achieve complete closure of VP port, however s/he has developed production of specific phonemes with nasal rather than oral pressure/flow/turbulence
Deficit is an error in articulation, not the VP mechanism
Sibilants and affricates
Inconsistent NAE

45. PSNAE

46. PSNAE

47. PSNAE

48. PSNAE

49. PSNAE Pick up a baby Take a teddy Go get a cookie Suzie sees horses
Should I shut it
Joey with a jar
A chicken ate a chip
(Leave Nasals out of it!)

50. When we refer
Before surgery
After surgery

51. When we refer Goal: -Eliminate compensatory or misuse
-Work on non pressure phonemes, vowel markers
-NOT nasality

52. When we refer After surgery -Eliminate compensatory
-Estimate if this is habitual, teach oral vs nasal
-May not need tx if placement was correct before surgery

53. Treatment Where to start?
Remember, separate out deficits. Working on manner? Stick with manner.

54. Treatment Don’t worry about manner re: nasality with compensatories
Hypernasality is not generally your goal
Teach placement with turbulence
Use of /m/ and /n/
Remember “puppy” may be “mummy”
Eliminate compensatory strategies

55. Treatment Liquids and glides Approximations, vowel markers
Treatment, not games.
-Token therapy, telling them when it’s wrong
Rapid phrases.
-How phrases changes phonemic sequence.

56. Things to avoid No oral motor Non speech tasks for majority of session
Holding nose during therapy
/k,g/- sometimes

57. Treatment Cues for bilabials, alveolar, velars Intrusive /h/
Frontalized /s/
Blowing with /f/
Blends
/t/for /ch/ and /d/ for /j/

58. Children work best with concrete, consistent cues
Children work best with concrete, consistent cues. They change their speech by what they feel

59. Blowing with /f/, intrusive /h/

60. /s/ with intrusive /h/

61. Rapid phrase

62. /s/ with intrusive /h/

63. Treatment /s/

64. Tx of /f/

65. Using approximations

66. Treatment of backing, decreasing complexity

67. Tx PSNAE, using approximations

68. Tx PSNAE

69. TX PSNAE

70. TX PSNAE

71. Tx glottal stopping

72. Bilabials

73. Alveolars

74. Tx of /k,g/

75. Tx of /s/

76. Nasal assimilation

77. Tx glottal stopping

78. Self monitoring

79. Tx of compensatory

80. Tx of compensatory

81. Final result

82. Kummer, A.W. (2001). Cleft palate and craniofacial anomalies: the effects on speech and resonance. San Diego, CA: Singular. *

83. Melissa Montiel, MS, CCC-SLP