Unit Eight Cleft Palate and Craniofacial Anomalies Copyright

Chapter 31 Anatomy and Physiology of the Resonatory System Copyright © 2008 Delmar. All

Embryological Development • Development of the lip and alveolar ridge begin around 6 weeks

Resonance • Normal resonance requires the intact anatomy and physiology of the following: –

Hard Palate • Anterior two-thirds of roof of mouth • Separates the mouth from

Soft Palate • Posterior one-third of roof of mouth • A muscular structure 6

Function of the Soft Palate • During quiet breathing – Soft palate is down

Causes of Clefting • No single cause of cleft • May be caused by:

Chapter 32 Types of Clefts and Associated Problems Copyright © 2008 Delmar. All rights

Cleft Lip • Unilateral – Cleft on one side • Bilateral – Both sides

Cleft Palate • Complete cleft palate – Opening through the hard palate and the

Submucous Cleft Palate • Cleft occurs underneath mucosal tissue of the palate • Possible

Incidence of Clefting • One in 750 live births • Cleft palate occurs more

Velopharyngeal Inadequacy • Velopharyngeal inadequacy (VPI) – Refers to abnormal velopharyngeal function – Results

Multicultural Groups and Clefts • Incidence of clefting differs across multicultural groups 15 Copyright

Feeding • Feeding is difficult for infants with clefting • Feeding difficulties can include:

Feeding • Feeding difficulties can cause: – Poor weight gain – Decreased nutrition 17

Successful Feeding Option • Specialized bottles and nipples • Different positions for holding the

Hearing and Clefting • Some craniofacial anomalies have associated ear deformities – Hemifacial microsomia

Hearing and Clefting • Children with cleft palate are at high risk for otitis

Functions of the Eustachian Tubes • Aerate the middle ear space • Equalize pressure

Hearing and Clefting • Children with clefts are prone to middle ear infection because

Dentition and Clefting • Dental anomalies in this population include: – Missing teeth –

Resonance Disorders • • Hypernasality Nasal air emission Hyponasality and denasality Cul-de-sac 24 Copyright

Hypernasality • An excessive amount of perceived nasal resonance • Oral and nasal cavities

Nasal Air Emission • Release of air pressure through the nose • Usually heard

Hyponasality • Reduction in nasal resonance during speech – Due to enlarged adenoids •

Denasality • Complete blockage in the nasal passages • Affects the nasal consonants –

Cul-de-Sac Resonance • Variation of hyponasality • Nasal sounds are trapped in a blocked

Articulation and Phonology • Children with clefts vary in their articulation skills • Velopharyngeal

Compensatory Articulation Errors • Children produce articulation errors to compensate for inadequate velopharyngeal closure

Glottal Stops • Most common compensatory error • Produced by adducting the vocal folds,

Language Delays and Differences • Children with clefts are reported to have: – Poorer

Chapter 33 Surgical and Speech Therapy Management Copyright © 2008 Delmar. All rights reserved.

Team Management • Optimal management for children with cleft lip and/or palate requires an

Function of a Team • • Evaluations Family counseling Make recommendations Plan the sequence

Team Members Oral surgeon Parents Plastic surgeon Prosthodontist SLP Orthodontist Child Audiologist E. N.

Cleft Lip Repair • Typically occurs between 2 nd and 3 rd month •

Cleft Palate Repair • Goal is to separate the oral and nasal cavities •

Secondary Surgery • Some children may require a second palate surgery if there is

Speech Appliances • Palatal lift – Lifts the soft palate when it is of

Speech-Language Evaluation • Evaluation is on-going but emphasis changes as child gets older •

Noninstrumental Tests • Mirror test • Nostril pinching • Air paddle 43 Copyright ©

Instrumental Procedures • • Nasometer Pressure-air flow technique Videofluroscopy Nasopharyngoscopy 44 Copyright © 2008

Interpreting Speech Assessment Data • Velopharyngeal function can be described as: – Competent –

Marginally Competent VP Function • Divided into two subgroups: – Almost-but-not-quite (ABNQ) – Usually

Speech Therapy: The First Years • Focus on feeding • Development of prerequisites for

Hypernasality and Speech Therapy • If the cause of the hypernasality is abnormal structure

Hypernasality and Speech Therapy Guidelines • Mild hypernasality • Inconsistent hypernasality • Articulation errors

Continuous Positive Airway Pressure (CPAP) • A therapy approach to improve hypernasality in some

Speech Therapy Techniques • • • Auditory discrimination Visual feedback Tactile-kinesthetic training Tactile feedback

Chapter 34 Emotional and Social Effects of Cleft Palate and Craniofacial Anomalies Copyright ©

Parents’ Initial Reactions to Clefting • Disbelief, shock, anger, guilt, depression, grief, anxiety, fear,

Family Systems Counseling • Considers each family member as part of a system –

Elementary School Age Children • Children with clefting are reported to feel more alienated,

Adolescence • Concerns with appearance are higher in adolescents with clefts, particularly in girls

Adults • Most adults with clefts fall within the typical range in terms of

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Embryological Development • Development of the lip and alveolar ridge begin around 6 weeks gestation • Development and fusion of the hard and soft palate is complete by 12 weeks gestation 3 Copyright © 2008 Delmar. All rights reserved.

Resonance • Normal resonance requires the intact anatomy and physiology of the following: – Facial structures – Articulators – Hard and soft palate – Pharyngeal region 4 Copyright © 2008 Delmar. All rights reserved.

Hard Palate • Anterior two-thirds of roof of mouth • Separates the mouth from the nose • Composed of three pairs of small bones: – Premaxilla – Palatine process – Palatine bone 5 Copyright © 2008 Delmar. All rights reserved.

Function of the Soft Palate • During quiet breathing – Soft palate is down allowing for breathing through the nose • During speech – Soft palate raises and move back to touch the posterior pharyngeal wall – This separates the nose from the mouth 7 Copyright © 2008 Delmar. All rights reserved.

Cleft Palate • Complete cleft palate – Opening through the hard palate and the soft palate • Cleft of the soft palate – Opening in soft palate often extending through the uvula 11 Copyright © 2008 Delmar. All rights reserved.

Submucous Cleft Palate • Cleft occurs underneath mucosal tissue of the palate • Possible signs of a submucous cleft – Bifid (split) uvula – Bluish color to palate 12 Copyright © 2008 Delmar. All rights reserved.

Incidence of Clefting • One in 750 live births • Cleft palate occurs more in females than males • Cleft lip with or without cleft palate occurs twice as often in males 13 Copyright © 2008 Delmar. All rights reserved.

Feeding • Feeding is difficult for infants with clefting • Feeding difficulties can include: – Poor oral suction – Poor intake of milk – Nasal regurgitation 16 Copyright © 2008 Delmar. All rights reserved.

Hearing and Clefting • Children with cleft palate are at high risk for otitis media and associated conducive hearing loss • Otitis media is caused by malfunction of the eustachian tube connecting the nasopharynx to the middle ear 20 Copyright © 2008 Delmar. All rights reserved.

Hearing and Clefting • Children with clefts are prone to middle ear infection because the muscles of the soft palate are not able to open the eustachian tubes in the normal way 22 Copyright © 2008 Delmar. All rights reserved.

Dentition and Clefting • Dental anomalies in this population include: – Missing teeth – Rotated and/or fused teeth – Bite issues due to jaw misalignment 23 Copyright © 2008 Delmar. All rights reserved.

Nasal Air Emission • Release of air pressure through the nose • Usually heard on: – Voiceless consonants, such as plosives (p, t, k) – Fricatives (s, f, sh) 26 Copyright © 2008 Delmar. All rights reserved.

Articulation and Phonology • Children with clefts vary in their articulation skills • Velopharyngeal inadequacy affects the production of many speech sounds • Manner of articulation is most affected 30 Copyright © 2008 Delmar. All rights reserved.

Glottal Stops • Most common compensatory error • Produced by adducting the vocal folds, building up air pressure under the glottis, then releasing • Typically substituted for plosives (p, b, t, d, k, g) 32 Copyright © 2008 Delmar. All rights reserved.

Language Delays and Differences • Children with clefts are reported to have: – Poorer receptive and expressive language – Shorter MLU – Reduced structural complexity – Smaller vocabulary 33 Copyright © 2008 Delmar. All rights reserved.

Team Members Oral surgeon Parents Plastic surgeon Prosthodontist SLP Orthodontist Child Audiologist E. N. T. physician Dentist Nurse Pediatrician Psychologist 37 Copyright © 2008 Delmar. All rights reserved.

Cleft Lip Repair • Typically occurs between 2 nd and 3 rd month • “Rule of 10” – Infants should be at least 10 weeks of age – Should weigh 10 lbs – Hemoglobin count of 10 grams 38 Copyright © 2008 Delmar. All rights reserved.

Cleft Palate Repair • Goal is to separate the oral and nasal cavities • Timing of surgery depends on surgeon’s philosophy: – Early: 6 -15 months – Late: 15 -24 months 39 Copyright © 2008 Delmar. All rights reserved.

Secondary Surgery • Some children may require a second palate surgery if there is VPI • One approach is to create a pharyngeal flap – Sew a flap of tissue from the back of the throat into the soft palate 40 Copyright © 2008 Delmar. All rights reserved.

Speech Appliances • Palatal lift – Lifts the soft palate when it is of sufficient length but does not move well • Palatal bulb – Fits into the pharyngeal port when the soft palate is too short 41 Copyright © 2008 Delmar. All rights reserved.

Speech-Language Evaluation • Evaluation is on-going but emphasis changes as child gets older • First concern: – Feeding • Then: – Language development • Then: – Speech development/intelligibility 42 Copyright © 2008 Delmar. All rights reserved.

Marginally Competent VP Function • Divided into two subgroups: – Almost-but-not-quite (ABNQ) – Usually associated with structural deficit – Sometimes-but-not-always (SBNA) – Usually associated with neurological or motor impairment 46 Copyright © 2008 Delmar. All rights reserved.

Speech Therapy: The First Years • Focus on feeding • Development of prerequisites for verbal communication • Compete speech and language evaluation by the age of 3 years 47 Copyright © 2008 Delmar. All rights reserved.

Continuous Positive Airway Pressure (CPAP) • A therapy approach to improve hypernasality in some children • Therapy involves resistance training against positive airway pressure 50 Copyright © 2008 Delmar. All rights reserved.

Parents’ Initial Reactions to Clefting • Disbelief, shock, anger, guilt, depression, grief, anxiety, fear, inadequacy, protectiveness • Parents need to receive information and counseling 53 Copyright © 2008 Delmar. All rights reserved.

Family Systems Counseling • Considers each family member as part of a system – Each member affects the others – System is interdependent – Within the system are subsystems 54 Copyright © 2008 Delmar. All rights reserved.