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Impact of VPI on Phonation
The published literature on cleft palate speech demonstrates that
phonatory disorders are more common in individuals with cleft palate
than in persons without clefts (Peterson-Falzone, et al., 2010, p. 240).
It is important to emphasize the distinction between voice problems
and resonance problems. Voice problems are limited to problems at the
level of the larynx (vocal folds, glois), whereas resonance problems
involve supralaryngeal cavities and structures (pharyngeal, oral, nasal).
Both cause speech production deviations. Hypernasality is not a voice
problem.
Although not all researchers and clinicians use terminology that
adheres to this distinction, technically it is appropriate to refer to
hypernasal speech but incorrect to refer to “hypernasal voice.” It is,
however, a clinically important difference because both diagnosis and
treatment are distinctly different for voice versus resonance problems.
Voice disorders most frequently associated with cleft palate are
hoarseness and what has become known as “soft voice syndrome,” the
laer being an intensity problem.
Hoarseness
It is commonly acknowledged that children with cleft palate are at
increased risk for developing vocal nodules as a result of laryngeal
hyperfunction. The nodules are believed to develop secondary to
abusive use of vocal folds as a compensatory speech valving
mechanism, especially for gloal stop production. Children who
present with combined problems of cleft palate and vocal hoarseness
are likely to have vocal nodules and underlying VP insufficiency. In
such cases, any speech treatment should be deferred until
comprehensive laryngeal and VP function studies have been completed.
Referral to a team is the best approach because a team is the best
resource for further diagnosis and treatment recommendations.
Soft Voice Syndrome
Soft voice syndrome describes a problem in which the cleft palate
speaker with VP insufficiency may intentionally talk more softly (reduce
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vocal intensity) to minimize or disguise hypernasality and NE. In this
sense, it is yet another compensatory strategy (Peterson-Falzone, et al.,
2010, p. 241). Speech treatment for this problem depends on VP
function, and further physical management may be necessary.
Soft voice syndrome is distinguished from the innate reduction in
loudness imposed VPI or VPD. In other words, hypernasality tends to
reduce vowel intensity, and speakers with VPI have difficulty
producing adequate loudness for conversational speech. Such speakers
may aempt to increase loudness by generating higher subgloic pressures
with associated greater supragloal airflow. This, in turn, may
aggravate perceived hypernasality and audible nasal air emission.
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Summary
• We use VPI (velopharyngeal inadequacy) as a generic term for “faulty
velopharyngeal closure,” which has many causes. Not all causes are
physically based. Some are learned and require no physical
management.
• VPI has an impact on resonance (hypernasality), on articulation (nasal
emission, compensatory articulations (CAs), and related backed or
retracted oral productions), and on phonation (voice quality and
intensity), all of which necessitate accurate assessment and diagnosis
and appropriate treatment.
• For most of you, the material on the nonoral CAs is probably the least
familiar. At this point, you may be asking, “What is important here?” It
is important that you remember that VPI during the speech
development years often results in a tendency for children to mislearn
place of articulation; namely, they tend to use a place of articulation
posterior to where it should be. This will help you understand and
implement a main goal of articulation therapy, which is to “move
backed articulations forward.”
• It is also important that you are able to recognize perceptually what is
compensatory and what is not and to identify generally the nonoral
locations of the deviant placements: gloal, pharyngeal,
velopharyngeal, and nasal. As a new learner of this material, it is less
important that you can identify exactly which compensatory
articulation you are hearing. With practice in listening and increased
clinical and professional experience, you will be able to learn the
perceptual differences between the compensatory stops (gloal,
pharyngeal, mid-dorsum palatal) and the compensatory fricatives
(pharyngeal, nasal). Learning the phonetic symbols is a maer of
memorization, as with all phonetics.
• Most importantly, you should have an appropriate strategy for
correcting CAs and related backed, retracted oral productions when
they present. Also, you should have realistic goals and expectations,
given the status of the child's velopharyngeal structure and function
and oral structural status.
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Other Consequences of Clefts
Speech-language pathologists (SLPs) treating children with clefts need
to be aware of three areas of concern, in addition to those discussed in
previous chapters: (1) dental and orthodontic issues; (2) hearing
problems; and (3) social, educational, emotional, and psychological
issues. Each of these has an impact on the well-being of the child and
family and affects how well the youngster will be doing when he or she
reaches young adulthood.
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