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Unit Eight

Unit Eight. Cleft Palate and Craniofacial Anomalies. Chapter 31. Anatomy and Physiology of the Resonatory System. Embryological Development. Development of the lip and alveolar ridge begin around 6 weeks gestation

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Unit Eight

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  1. Unit Eight Cleft Palate and Craniofacial Anomalies

  2. Chapter 31 Anatomy and Physiology of the Resonatory System

  3. 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

  4. Resonance • Normal resonance requires the intact anatomy and physiology of the following: • Facial structures • Articulators • Hard and soft palate • Pharyngeal region

  5. 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

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

  7. 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

  8. Causes of Clefting • No single cause of cleft • May be caused by: • Single genes • Chromosomal disorders • Environmental factors

  9. Chapter 32 Types of Clefts and Associated Problems

  10. Cleft Lip • Unilateral • Cleft on one side • Bilateral • Both sides of the lip are affected

  11. 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

  12. Submucous Cleft Palate • Cleft occurs underneath mucosal tissue of the palate • Possible signs of a submucous cleft • Bifid (split) uvula • Bluish color to palate

  13. 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

  14. Velopharyngeal Inadequacy • Velopharyngeal inadequacy (VPI) • Refers to abnormal velopharyngeal function • Results in hypernasal speech

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

  16. Feeding • Feeding is difficult for infants with clefting • Feeding difficulties can include: • Poor oral suction • Poor intake of milk • Nasal regurgitation

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

  18. Successful Feeding Option • Specialized bottles and nipples • Different positions for holding the baby • Monitoring the duration of feeding

  19. Hearing and Clefting • Some craniofacial anomalies have associated ear deformities • Hemifacial microsomia • Treacher Collins

  20. 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

  21. Functions of the Eustachian Tubes • Aerate the middle ear space • Equalize pressure in the middle ear • Drain middle ear fluid into the nasopharynx

  22. 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

  23. Dentition and Clefting • Dental anomalies in this population include: • Missing teeth • Rotated and/or fused teeth • Bite issues due to jaw misalignment

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

  25. Hypernasality • An excessive amount of perceived nasal resonance • Oral and nasal cavities are joined • In speech • Particularly noticeable on vowels

  26. 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)

  27. Hyponasality • Reduction in nasal resonance during speech • Due to enlarged adenoids • Affects the nasal consonants • m, n, ng

  28. Denasality • Complete blockage in the nasal passages • Affects the nasal consonants • m, n, ng

  29. Cul-de-Sac Resonance • Variation of hyponasality • Nasal sounds are trapped in a blocked passage • Speech sounds “muffled”

  30. 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

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

  32. 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)

  33. Language Delays and Differences • Children with clefts are reported to have: • Poorer receptive and expressive language • Shorter MLU • Reduced structural complexity • Smaller vocabulary

  34. Chapter 33 Surgical and Speech Therapy Management

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

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

  37. Team Members

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

  39. 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

  40. 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

  41. 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

  42. Speech-Language Evaluation • Evaluation is on-going but emphasis changes as child gets older • First concern: • Feeding • Then: • Language development • Then: • Speech development/intelligibility

  43. Noninstrumental Tests • Mirror test • Nostril pinching • Air paddle

  44. Instrumental Procedures • Nasometer • Pressure-air flow technique • Videofluroscopy • Nasopharyngoscopy

  45. Interpreting Speech Assessment Data • Velopharyngeal function can be described as: • Competent • Marginally competent • Incompetent

  46. 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

  47. 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

  48. Hypernasality and Speech Therapy • If the cause of the hypernasality is abnormal structure • Speech therapy is NOT appropriate

  49. Hypernasality and Speech Therapy Guidelines • Mild hypernasality • Inconsistent hypernasality • Articulation errors for which the child is stimulable

  50. Continuous Positive Airway Pressure (CPAP) • A therapy approach to improve hypernasality in some children • Therapy involves resistance training against positive airway pressure

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