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tongue blade vertically between the teeth. Please see Appendix 7-B for
guidance and hints on how to approach a child, especially a young or
not-so-cooperative child, to obtain a good orofacial exam.
Crucial Observation: Allergic Shiners
If a child presents to you with “allergic shiners” (meaning dark circles
beneath the eyes) or a consistent open mouth posture, or both, he or she
is probably having difficulty breathing at night. Ask the parents about
snoring, restlessness, daytime sleepiness, and other issues. Most likely,
the child's speech will be hyponasal. The possibility of sleep apnea needs
to be explored because this is not a benign condition.
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Summary
Many structural factors can affect speech production and
understandability or intelligibility in children with repaired cleft lip and
palate (insufficient VP closure, a fistula, dental and malocclusion
problems). Although distortions caused by dental and occlusal
problems do not render speech unintelligible, they contribute yet
another source of speech deviation in this population. Generally, they
do not affect speech to the extent that VPI/VP dysfunction does, but
they are nevertheless factors that reduce speech clarity.
The task of the SLP is to listen to the speech, document the paerns,
and try to relate the paerns to oral structural and velopharyngeal
findings. Obtaining good orofacial information may save you, the child,
and the child's parents from wasting time and effort in speech therapy
that may not be productive because important physical findings have
been missed. For quick reference, Appendix 7-C provides a summary of
structures to be examined in the orofacial exam. This is especially useful
to students learning this material and to working professionals new to
the area of cleft lip and palate.
APPENDIX 7-A
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Brief Oral Mechanism Exam
1
APPENDIX 7-B
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Approach to a Youngster: Some
Guidelines and Tips
NOTE: Many children will allow the orofacial exam without much
resistance and you may be able to use your gloved finger in place of the
tongue blade. However, for children who do resist, here are some
suggestions:
• Before you bring out the flashlight and tongue blades, have the child
do a lile “mugging” in imitation of you. What he is able to do may
give you some information about muscular symmetry, but it will also
be an opportunity for a lile fun before the two of you get to work.
Have him imitate you puffing up your cheeks, pursing your lips,
blowing kisses, wiggling your tongue from side to side, and so forth.
Depending on the age of the child, make funny faces for him to imitate
after you.
• It may be useful to give the child a tongue blade so he can take off the
paper, explore it, and be comfortable with it. Open a tongue blade
yourself, put it into your mouth, and show him the inside of your
mouth. If you have the time, let the child handle that tongue blade and
do an oral exam on you. Then you can say, “OK, let's see your mouth!”
Now open a new tongue blade.
• At this point, tell the child to put his teeth together and keep his lips
tightly closed. Now bring out the tongue blade and just touch the
closed lips. Depending on how playful he is, say, “Now don't let me
get in there” (meaning inside the mouth). “Keep your teeth shut
really
tight! Make ‘grrrr’ like a tiger so I'll be very scared.” This can give the
child the feeling of being the gate-keeper (of being the one in control).
While he is enjoying this feeling, simply slip the tongue blade,
sideways, into each labial sulcus, still urging him to keep his teeth
closed. You can explore how the teeth fit together toward the back of
the mouth and examine for a posterior open bite, but, more
importantly, this approach lets the child be less fearful because the
tongue blade does not feel like a threat. Then you can say, “OK, now
just open a lile bit—not too much!” If he is still comfortable, you can
coax him a lile further with, “OK, now a lile wider.”
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• At this point, take the tongue blade out and say, “Can you make me a
really big AH?” Your goal at this point is to observe any movement in
the velopharyngeal system (primarily if the velum elevates) without
the tongue blade pressing down on the base of the tongue. If you do
not feel you have obtained a sufficient view, then you can introduce
the tongue blade and press down on the tongue, although this is likely
to produce a negative response in the youngster. (Hint: The most likely
area to trigger a gag response is not the tongue but the palatal area
nearest the last molars.)
• If you need to see the back of the mouth more clearly than you have
been able to do up to this point, use the sneaky approach of turning
the tongue blade (you may need two) sideways and placing it between
the posterior upper and lower teeth to “prop the mouth open.” This
will prevent the child from biting your finger in defense. The child
may be upset when he realizes that he has lost control of the situation
because he can no longer close his mouth. You will have to be quick:
While he is whimpering in protest, get a good look at the movement of
the velopharyngeal system. Then: Get out and make a big show of
breaking the tongue blade in two and saying “All done!” He will likely
forgive you and stop whimpering once he sees that your weapon (the
tongue blade) has been destroyed.
APPENDIX 7-C
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Summary of Orofacial Exam and
What to Look For
STRUCTURE WHAT TO LOOK FOR
Lips • Competence; length (philtrum); symmetry
• Frenulum; sulcus (check for fistulas)
• Movements for rounding, compressing, spreading
Nose • Anterior patency
• Interior patency (bowed septum)
Dentition • Missing teeth; rotated teeth
• Extra teeth: supernumerary or duplicated
• Ectopic teeth (note location re: speech targets for these deviations)
Occlusion • Overjet, protrusive premaxilla
• Underjet, with and without class III malocclusion
• Open bites (location)
• Lateral or buccal crossbites; reduced maxillary width
Tongue • Ankyloglossia (anteriorly displaced or shortened lingual frenulum);
impact on range of motion, precision?
• Relative tongue size
• Microglossia, glossoptosis, and other anomalies occurring in
syndromes
• Symmetry during protrusion, elevation
Hard palate and alveolus • Fistulas (always note location and patency)
• Alveolar or nasolabial
• Palatal (anterior, midpalate, posterior)
• Submucous cleft palate (SMCP)
• Continuum of intraorally visible findings
• Cannot see occult SMCP intraorally
Velum and faucial isthmus (anterior
and posterior pillars)
• Bifid uvula (suspect submucous cleft)
• Absent uvula
• Velar length; symmetry at rest and during phonation
• Velopharyngeal gag response
• Tonsil size and position (may be obstructive to VP closure; requires
imaging study)
Modified from Peterson-Falzone SJ, Trost-Cardamone JE, Karnell MP, Hardin-Jones
MA: The clinician's guide to treating cleft palate speech. St. Louis: Mosby, 2006.
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References
Baylis A, Chapman K, Dixon A, et al. Americleft Speech Outcomes
Project. [American Cleft Palate-Craniofacial Association (ACPA)
website] hp://www.acpa-
cpf.org/research/the_americleft_outcomes_project/ [(Go to
download Americleft Study Guide); Accessed February 25,
2016].
Folk SN, D'Antonio LL, Hardesty RA. Secondary cleft deformities.
Clin Plast Surg. 1997;24:599–611.
Kummer AK. Ankyloglossia: to clip or not to clip? That's the question.
[ASHA Leader] December, 2005.
Online Mendelian Inheritance in Man (OMIM). Available at
OMIM.org. Accessed July 15, 2015.
Peterson-Falzone SJ. Velopharyngeal inadequacy in the absence of
overt cleft palate. J Craniofac Genet Dev Biol Suppl. 1985;1:97–124.
Trost-Cardamone JE. Cleft palate speech: a comprehensive 2-part set.
[American Speech-Language-Hearing Association (ASHA)
Professional Development Course (with three DVDs and
accompanying course pack); Available through ASHA
Bookstore at] www.asha.org/shop; 2013 [Accessed February 25,
2016].
Warren DW, Bevin AG, Winslow RB. Posterior pillar webbing and
palatopharyngeal displacement: possible causes of congenital
palatal incompetence. Cleft Palate J. 1978;17:68–72.
1
Taken and modified with permission from the Americleft Speech Outcomes Project,
unpublished data collection protocol (2014). Developed by the Americleft Speech
Group: Baylis A, Chapman K, Dixon A, Dobbylsteyn C, Thurmes A, Trost-Cardamone
J, and Wilson K. See ACPA website:
hp://www.acpa-
cpf.org/research/the_americleft_outcomes_project/
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Perceptual Assessment of Speech
Perceptual identification is the cornerstone for all speech assessment
and diagnosis. For the clinical population that is the focus of this book,
the speech-language pathologist (SLP) must first decide what is present
in the “perceptual speech package” presented by the child (or adult)
and then look for the physical underpinnings of the perceived speech
deviations. The perceptual speech findings lead the SLP in deciding on
the need for any or all of the following:
• Instrumental assessment
• (Further) physical management
• Speech therapy and the purpose of that therapy
Many SLPs may treat children with clefts infrequently and may have
had minimal academic coursework in cleft palate and velopharyngeal
dysfunction (VPD) and lile to no clinical experience assessing and
treating cleft palate speech disorders. This chapter offers a systematic
approach intended to guide the SLP through steps in the perceptual
assessment process that will yield an accurate speech diagnosis in a
child with a cleft palate and/or “hypernasal speech.”
The label “hypernasal speech” often is used generically to identify the
triad of resonance, nasal airflow or air emission, and weak oral
pressure parameters of VPI, even though nasality deviations are
purely resonance disorders. Do not assume that when you get a
referral of a child with “nasal” or “hypernasal” speech that resonance
is the only problem.
This material provides a basis for making an informed referral to a
cleft palate or craniofacial team for a youngster who needs a team
consultation. For a youngster already under team care, contact with the
team can facilitate dialogue and collaborative interaction between the
community-based or school-based SLP and the managing team and
team SLP. This is an important interaction both for mutual
understanding of team recommendations and for planning and
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executing therapy for cleft-related speech errors. For those readers who
are familiar with craniofacial speech disorders or who may be “old
timers” in cleft care, we hope this material serves as a helpful review of
the salient ingredients of cleft palate speech assessment and diagnosis.
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