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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_33_библиотеки_им_акад_М_И_Перельмана
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/j/, gloal stop, and /h/. The “prey funny” grunting sound that the
parents describe is likely a pharyngeal fricative-type production.
“Bobby” has no oral stops, no anterior palatal placements, and exhibits
an early paern of speech sound backing.
Recommendations
1. Parents and baby are in need of early speech intervention on a once
or twice monthly basis for instruction and guidance on how to
discourage pharyngeal and gloal productions and encourage oral
sound play in order to expand the sound inventory.
2. The program could be either home based or clinic based.
3. Team follow-up postpalatoplasty.
Baby/Toddler: Age 16 to 18 Months
Clinical Findings/Presenting Problems
1. First visit to cleft palate team at age 11 months.
2. Cleft palate only (palatoplasty done at 12.5 months with [late]
placement of PE tubes at the time of surgery).
3. History of intermient otitis media with effusion since infancy;
treated with medication.
4. Bilingual language environment; predominantly Spanish (mother
bilingual for Spanish and English; father and grandmother speak
Spanish only).
5. Naming vocabulary of 10 to 15 words (Spanish) at age 17 months by
parental report; mother not sure how much “Anna” understands but
feels she knows familiar foods, toys, and clothing items.
6. Reluctant to engage in interactive play with clinician; parents report
a speech sound inventory of “vowels” and /m/ which she uses to start
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most word aempts, and they say she also makes “growling sounds”
and “blows air through her nose” when “talking” to her toys.
Speech/Communication Diagnosis
“Anna's” naming vocabulary is developing slowly. Her speech sound
inventory is restricted to vowels and /m/ (at 4.5 months
postpalatoplasty), and uerances are also characterized by growls (that
may be early pharyngeal fricatives) and audible nasal air emission that
may be intentional (i.e., learned nasal fricatives). Velopharyngeal
insufficiency cannot be ruled out at this time, and “Anna” should be
monitored for possible delay in speech sound acquisition and oral
expressive language.
Recommendations
1. Enroll in an early speech and language intervention program with
the focus on parent training, so parents can carry out therapy goals for
their child in a naturalistic seing.
2. Ideally, the therapist is bilingual in English and Spanish; the
program can be home-based or clinic-based, and should engage and
“coach” the parent (or grandparent) on how to model and facilitate oral
sounds and not reinforce “throat” and “nose” sounds. A clinic-based
program can provide interaction with other toddlers and their parents.
3. Initial speech articulation focus should include: (1) establishing
imitative sound play behavior and activities to encourage oral airflow
and discourage the nasal fricatives; (2) expanding the speech sound
inventory; and (3) building a naming vocabulary using sounds already
in her inventory (i.e., vowels and /m/) and incorporating others as they
emerge.
4. Team follow-up in 6 months; speech to be monitored for possible
persisting VPI and impact of early intervention progress on speech
sound inventory and early language development.
5. Refer for audiologic/sound field testing before returning for next
team visit.
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Baby/Toddler: Age 24 Months
Clinical Findings/Presenting Problems
1. Repaired left unilateral cleft lip and palate (palatoplasty and
placement of pressure equalizing (PE) tubes, which are still in place,
done at age 8 months; hearing WNL).
2. Good lip mobility, no fistulas, no dental or occlusal deviations;
tonsils appear small on intraoral exam.
3. Phonetic inventory: [m, n, w, p, b, j,
, ɡ, h]; “s”-like sound that
varies with velar and mid-dorsum palatal fricatives; gloal stops.
4. Mild continuous hypernasality; audible intermient nasal air
emission on word-final pressure consonants and coproduced with
aempted blowing.
5. Language at least grossly WNL.
6. Speech understandable most of the time when context is known.
7. Error paerns: palatalization and velarization of [t, d, s] (i.e., backed
oral productions resulting in mid-dorsum palatal stops and [s] backed
to
or ; [t, d] targets backed to [k, ɡ]); intermient gloal stop
replacements for word final and intervocalic pressure consonants
(especially evident in short connected speech uerances).
Speech/Communication Diagnosis
“Austin” presents with a mildly restricted phonetic inventory for his
age ([t, d] are absent) and early developing cleft type error paerns of
backed oral productions of [t, d, s] and gloal stop substitutions.
Speech uerances are sometimes hard to understand and are
characterized by mild hypernasality (rating of 1) and intermient nasal
air emission which may be indicative of marginal (possibly
veloadenoidal) VP closure.
Recommendations
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1. Establish a home program for speech intervention with bimonthly or
monthly parent teaching and follow-up sessions with the SLP; the
initial goals of the program are to:
• Model and facilitate anterior placements for [t, d]
• Teach oral versus nasal direction and control of airflow
through blowing activities (the purpose is not to use
blowing to work on beer VP closure)
• Use “s-like” production to facilitate expansion of oral
fricatives
• Target postvocalic [p] to break up word final gloal
stop paern
2. Team follow-up in 6 months to monitor for changes in compensatory
nonoral and oral backing paerns and VP closure status.
Preschool: Age 3 to 5 Years
Clinical Findings/Presenting Problems (Age 4
Years)
1. Orofacial exam within normal limits; no physical evidence of VP
inadequacy; no perceptible hypernasality.
2. Nasal fricatives substituted consistently for sibilant fricatives and
affricates /s, z,
, , /; developmental errors [w/r] and inconsistent
fronting of /k/; articulation otherwise within normal limits for age.
3. Intermient mild dysfluency that parents feel is decreasing.
4. Stimulable for clear oral “s” production using a “long [t]” as a
facilitative context. (e.g., [t: → s]).
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Speech Diagnosis
“Jeremy” presents with phoneme-specific nasal emission on the sibilant
fricatives and affricates, while the other pressure consonants in his
inventory are articulated normally. This appears to be a learned paern
and not related to VP insufficiency.
Recommendations
1. Refer for instrumental/imaging assessment to verify adequate VP
closure ability; no physical management.
2. Enroll in individual speech therapy now with the focus on
articulation and priority on eliminating nasal fricatives. Monitor the
dysfluency and initiate therapy if it worsens or does not continue to
resolve on its own.
3. Follow-up team consultation, as necessary or requested, in 1 year or
sooner.
Preschool: Age 3 to 5 Years
Clinical Findings/Presenting Problems (Age 3
Years, 8 Months)
1. Adopted from Russia and entered the United States 8 months ago, at
age 3 years.
2. Repaired right unilateral cleft lip and palate (lip repair at 10 months
in Russia; palatoplasty and bilateral PE tubes placed at age 3-6, two
months ago; hearing WNL).
3. Good lip mobility; no oronasal fistulae; full primary dentition; tonsils
appear small; uvula “split,” and palate appears short intraorally.
4. Learning English rapidly; using two- to four-word uerances; speech
understandable about half of the time, primarily on the basis of vowel
nuclei.
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5. Consonant phonetic inventory includes [m, n, w, j]; [h] emerging;
rampant gloal stops, which mark most pressure consonant targets; no
“true” consonants.
6. Mild to moderate hypernasality; nasal air emission evident on
blowing but minimal in speech uerances because of frequent gloal
stopping and release.
Speech Diagnosis
“Maria” presents with a severe speech disorder characterized by a
restricted phonetic inventory (she has no pressure consonants), mild to
moderate hypernasal resonance (rating of 1 to 2), and rampant gloal
stops. Although the late repair of her unilateral cleft lip and palate and
late placement of PE tubes probably are etiologic, her recent entry into
the United States, where she is confronted with a new sound system,
may also be contributory to gloal stopping. She is learning the English
language rapidly.
Recommendations
1. Enroll in intensive individual speech therapy as soon as possible,
with the main goal of normalizing and expanding the phonetic
inventory.
2. Establish oral airflow as prerequisite to fricative manner.
3. Establish oral placements.
4. Eliminate gloal stopping.
5. Team follow-up in 6 months; determine readiness and need for
imaging study of VP function at that time.
School Aged: Age 6 Years
Clinical Findings/Presenting Problems
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1. Repaired left unilateral cleft lip and palate; no secondary surgery has
been performed to date.
2. Good lip mobility and a mild crossbite in the area of the cleft
alveolus; the tonsils are present and small; the examination is otherwise
unremarkable.
3. Moderately severe hypernasality, audible nonturbulent nasal air
emission; gloal stop substitutions or coproductions for most high
pressure consonant targets/targets are sometimes omied or produced
as nasal fricatives; conversational speech understandable about half of
the time; stimulable for oral placements for “f,” “sh,” and “s” in CV
contexts, all accompanied by nasal emission.
4. Receiving individual public school speech therapy three times
weekly; therapist is requesting guidance with goals and techniques.
Speech Diagnosis
“Joey” presents with a severe speech disorder characterized by
moderately severe hypernasality (rating of 3), nasal air emission,
rampant gloal stops, and occasional nasal fricatives, all of which
significantly compromise speech understandability. Suspect persisting
VP insufficiency but gloal stop–induced VP inadequacy cannot be
ruled out based on these clinical findings.
Recommendations
1. Refer for videonasendoscopy of velopharyngeal function to rule out
gloal stop–induced VP inadequacy and to evaluate the roles of
adenoid and tonsils in closure; defer to physical management, as
indicated.
2. Continue school-based individual speech therapy program. Focus on
establishing oral fricatives before beginning work to eliminate gloal
stops.
3. Provide requested guidance to school SLP; offer collaborative
teaching session with parent and child.
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4. Team follow-up in 6 months.
School Aged: Age 8 Years
Clinical Findings/Presenting Problems
1. Intermient mild hypernasality in connected speech.
2. Nasal turbulence coproduced intermiently and infrequently with
fricative sounds (e.g., /f, s, z,
/) and most perceptible when the speech
context contained nearby or contiguous nasal consonants.
3. Consistent inaudible nasal emission detected via mirror fogging
during repeated/serial productions of pressure consonants.
4. Complete phonetic inventory with no placement errors.
5. Orofacial exam revealed a “short-appearing” but mobile soft palate,
and the lower margin of adenoid could be seen on phonation of
vowels; exam was otherwise unremarkable.
Speech Diagnosis
“Sarah's” speech is easy to understand all of the time but characterized
by intermient mild hypernasality (rating of 1) and infrequent nasal
turbulence associated with fricatives that appears to be an assimilation
effect of surrounding nasal consonants. Because the inferior margin of
adenoid is observed intraorally and the velum appears “short,” it is
possible that velopharyngeal closure is being aided by an enlarged
adenoid and is marginal at this time. This puts “Sarah” at some risk for
developing more notable velopharyngeal insufficiency as or if adenoid
diminishes further.
Recommendations
1. Refer for videonasendoscopy study to beer define velopharyngeal
closure physiology and adequacy and the role of adenoid in closure.
2. Team team follow-up in 1 year.
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School Aged: Age 10 Years
Clinical Findings/Presenting Problems
1. Repaired bilateral cleft lip and palate; no secondary surgery to date.
2. Angle class III malocclusion; no fistulas.
3. Mild hypernasality (rating of 1); inaudible and inconsistent nasal
emission.
4. Pharyngeal fricative substitutions for “s” and “z”; gloal stop
[inconsistent] for “k”; pharyngeal stop [inconsistent] for “g.” These
sounds are correct in some phonetic contexts. Making progress
eliminating these errors in public school speech therapy.
5. Dentalization of tip alveolars and diffuse production of “sh” and
“zh.”
Speech Diagnosis
“Aaron's” speech is understandable most of the time but characterized
by mild hypernasality, inconsistent and inaudible nasal emission
(suggestive of marginal VP closure), and compensatory substitutions
for “s” and “z” (pharyngeal fricatives), “k” (gloal stop), and “g”
(pharyngeal stop). He presents speech sound distortions, especially
mild frontal lisping, secondary to his class III/underbite malocclusion.
Recommendations
1. Refer for visual imaging studies of VP function to confirm and
define, or rule out, marginal VP insufficiency, and determine the need
for and potential benefit of physical management at this time.
2. Continue in-school speech therapy with additional focus on
elimination of pharyngeal fricatives.
School Aged: Age 12 Years and Older
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Clinical Findings/Presenting Problems (Age 16)
1. Right hemifacial microsomia with repaired right unilateral cleft lip
and palate (palatoplasty at age 11 months); atresia of the right ear canal
with moderate unilateral conductive hearing loss.
2. Moderate right crossbite (recent distraction procedures have not
benefited the crossbite); it continues in orthodontic follow-up.
Conversational speech easy to understand all of the time but
characterized by inconsistent velarization of “n”
, mixed
resonance, lateralized production of sibilants.
Speech Diagnosis
“Angela's” speech is understandable all of the time but characterized by
mixed resonance, inconsistent backing of “n” to velar place, and mild
sibilant distortions probably related to the right crossbite malocclusion.
Recommendations
1. Speech therapy is optional depending upon any social consequences
of these mild deviations and “Angela's” desire to further improve
articulation; the mixed resonance is socially acceptable; more precise
production of sibilant distortions is limited by the crossbite imposed by
the shortened, asymmetric mandibular ramus.
2. Team follow-up in 1 year.
3. Angela and her parents have been counseled to contact the team SLP
if interested in pursuing therapy to eliminate the velarized /n/.
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