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 - 8700 Shoal Creek
Boulevard, Austin, TX 78757, 512-451-3246.
– Nasal tube to water.
– Nasometer
 Resources
• http://craniofacialcenter.uiowa.edu:88/speechpat
h/Instruction/new_speech_therapy/vpi_st_01.ht
ml
• http://hsc.virginia.edu/cmc/tutorials/cleft/
• http://www.pedisurg.com/PtEduc/Cleft_Lip-
Palate.htm
• http://www.hopkinsmedicine.org/craniofacial/Edu
cation/PalateQT.cfm
• http://hsc.virginia.edu/cmc/tutorials/cleft/causes
%20and%20risk%20factors.htm