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FIGURE 7-15 An obvious submucous cleft with a tiny uvula
rather than a bifid uvula.
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FIGURE 7-16 All three stigmata of an overt submucous cleft:
bony defect in the hard palate, zona pellucidum (thin, pale tissue)
in the soft palate, and a bifid uvula.
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FIGURE 7-17 On just one quick intraoral view, the examiner
may miss the presence of a submucous cleft, which is clearly
seen on elicitation of phonation.
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FIGURE 7-18 The velar tissue in this submucous cleft was so
thin that it tore prenatally, so that the individual presented with a
congenital palatal fistula.
FIGURE 7-19 This is a post-op photo of a repaired palate in
which the repair was not carried all the way through the uvula;
thus it looks like a bifid uvula. (From Trost-Cardamone JE: CDS 660:
Structural organic disorders of speech: graduate course, California State University at
Northridge, Northridge, CA.)
Pharyngeal Musculature and Tonsils
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1. As you know, the anterior faucial pillars are composed of the
palatoglossus muscle and the posterior pillars of the palatopharyngeus
muscle. The palatine tonsils sit in the oropharynx, between the anterior
and posterior pillars. An extreme case of enlarged tonsils is seen in
Figure 7-20. The tonsils are normally too low in the pharynx to
influence VP closure in speech, but the upper poles of enlarged tonsils
may extend high enough to be positioned between the velum and the
posterior pharyngeal wall, thus contributing a mechanical interference
to VP closure, as discussed in Chapter 5. Videonasendoscopy or
videofluoroscopy is required to examine the role of tonsils in VP closure
in such cases. In the x-ray studies seen in Figure 7-21, the enlarged
tonsillar mass does not interfere with closure but appears to prevent the
velum from dropping into a normal rest position.
FIGURE 7-20 Very large tonsils in a child with hypernasal
speech. The tonsils sit behind the anterior faucial pillars but
protrude medially to almost meet in midline. Tonsillar poles
cannot be seen. (From Trost-Cardamone JE: CDS 660: Structural organic
disorders of speech: graduate course, California State University at Northridge,
Northridge, CA.)
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FIGURE 7-21 Enlarged tonsils in an 11-year-old as seen on
lateral cephalometric radiograph taken at rest and on production
of interdental fricative.
2. On phonation, you may see medial movement of one or both sets of
pillars or perhaps movement of the lateral pharyngeal musculature just
behind the posterior pillars. Such movement may or may not contribute
to closure of the VP mechanism. Again, a dynamic visual imaging study
is required to view and understand the physiology of VP closure.
3. There have been a few reported cases of webbing of the posterior
faucial pillars, which could conceivably inhibit velar movement (Warren
et al., 1978) and as shown in Figure 7-22. Because we have no way of
knowing how often posterior pillar webbing occurs, we cannot know
how often it influences VP closure.
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FIGURE 7-22 Webbing of the posterior faucial pillars. Such
webbing can inhibit upward and back movement of the velum, as
reported by Warren, Bevin, and Winslow in 1978. (From Trost-
Cardamone JE: CDS 660: Structural organic disorders of speech: graduate course,
California State University at Northridge, Northridge, CA.)
4. The literature is full of articles on the subject of the contribution of
both lateral pharyngeal wall movement toward the midline and
posterior pharyngeal wall movement anteriorly to VP closure in speech.
This topic is discussed in Chapter 5. On your intraoral exam, you may
be able to make only minimal judgments about Passavant's pad activity
or other movements of the lateral or posterior pharyngeal wall
musculature. However, it will be important for you to record your
observations and forward them to other professionals, particularly the
team and surgeon caring for the youngster. Definitive description of the
degree to which pharyngeal wall motion is or is not contributing to VP
closure depends on videofluoroscopic or nasopharyngoscopic
(videoendoscopic) studies.
Adenoid Pad
Although the tonsils and the adenoid pad are both lymphoid tissue and
both are parts of what is called Waldeyer's ring, they have disparate
origins and disparate growth cycles. Thus, in a growing child, the
tonsils may be large and the adenoid small, or vice versa. The adenoid
pad, positioned in the posterior nasopharynx, is much more likely than
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the tonsils to have an influence on or a role in “VP” closure (Figs. 7-23,
7-24, and 7-25).
FIGURE 7-23 This youngster's adenoid pad is so far forward
that he cannot get the velum away from it.
FIGURE 7-24 Both the tonsils and the adenoid pad are
enlarged in this youngster.
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FIGURE 7-25 This youngster has an enlarged adenoid pad but
may be dependent upon it for closure.
It has long been known that VP closure in youngsters is usually
“velo-adenoidal” closure. For children with congenitally short palates
or short palates due to clefts, the adenoid pad can be a blessing, by
preventing VPI. In childhood, when the adenoid tissue normally
involutes (diminishes in size), what had been normal speech can
gradually become speech affected by VPI. The same is also true if the
adenoid pad is removed in a youngster who is adenoid dependent for
closure. In the 1960s, 1970s, and 1980s, numerous reports noted that VPI
was “unmasked” by adenoidectomy (Peterson-Falzone, 1985). As the
on-site SLP, it is important to recognize what has transpired in such a
child's growth cycle or medical history, and to be aware of the
appropriate referrals to make, knowing that speech therapy cannot
change an excessively deep pharynx or a functionally short velum.
For a narrated video on the orofacial exam with patient examples, see
the professional course, Cleft Palate Speech, A Comprehensive 2-Part
Set, by Trost-Cardamone (2013), published by the American SpeechLanguage-Hearing Association. www.asha.org/shop
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Equipment, Setting, and Additional
Observations
The equipment for performing an intraoral exam on a youngster is as
follows:
• A strong flashlight (a small penlight works well)
• Several sterilized tongue blades (i.e., in paper sheaths): give one to the
child to play with so he or she does not have to be afraid of it
• Sterile gloves
• A parent or other assistant if the child is a toddler or preschooler
• A sense of humor
Some Comments on the Physical Setting
If you are not in a medical or dental facility but are doing this oral exam
in a “speech therapy room,” how you position yourself and how you
position the child will depend on the size and maturity of the child and
will play a key role in how successful you are in seeing what you need
to see. Toddlers and preschoolers will be most comfortable on a parent's
lap. Initially, you do want the child upright, not in a supine position on
the lap. A school-age child should be comfortable on a chair. The
difficult part may be geing your own head level at the level of the
child's head. You do not want the child tipping his or her head back, at
least not until you reach that point in the exam where you need the best
possible view of the area just behind the maxillary incisors. This is the
area where many fistulas hide. Most children at the third-grade level
and older can simply stand in front of you as you sit; your head levels
should match. It may help if a parent or one of your colleagues is
present to help hold the child's head steady as you examine the mouth.
Some children may be fearful or otherwise upset, and you may need
to use a rather indirect approach to accomplish the orofacial exam. If it
is necessary to palpate the palate, you may first want to give the child a
sterile glove to let him or her use it to explore the inside of your mouth.
School-age children do not need this step, but preschoolers may. With
toddlers, you simply have to proceed with the examination and get in
and out of the mouth quickly. Do not forget the trick of placing a
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