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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_4578_Библиотеки_им_академика_М_И_Перельмана
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The Orofacial Exam
What to Look For
The goal of any orofacial exam in speech pathology is to identify
structural or oral motor problems that may explain the presenting
speech problem. In the cleft lip and palate/craniofacial disorders
population our focus is more on structures, but we always need to do as
comprehensive an evaluation as possible within the inherent time
constraints. Very often in craniofacial clinics, where children are seen by
numerous specialists, the speech-language pathologist (SLP) can
accomplish only a screening examination. The same time crunch exists
in the public school seing. The focus in this chapter is on the oral and
oropharyngeal structural deviations that have an impact on speech
behavior (articulation, resonance, and airflow).
As the SLP assessing the speech problems present in a child with a
cleft, noncleft velopharyngeal (VP) inadequacy (VPI), or a history of
either of these problems, you will need to perform a careful
examination of both the oral cavity and its surrounding facial
structures. This is your responsibility even if the child is sent to you
with a supposedly detailed physical examination and history. Given
that the orofacial exam is initially a screening procedure, it should not
take more than 5 to 10 minutes.
Appendix 7-A contains a sample form to use in your examination, in
the event that you do not already have one. These forms tend to be a
work in progress with periodic modifications. After you have used it a
few times, you may find that you want to modify it, based on what you
have learned. Often, oral mechanism examinations are performed too
quickly, and sometimes with a fearful youngster. Do not give up and
just say, “Child uncooperative.” There are ways to deal with lack of
cooperation, and initiating speech therapy for a youngster with a cleft
or other VP problem without examination of the oral structures is not
advisable. It is necessary, however, to be realistic about how detailed an
exam you can do, given the time constraints you have, and to
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understand that the orofacial exam should be tailored toward covering
those structures that you suspect are affecting speech in this particular
child.
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Why “Orofacial”?
Although the intraoral examination is the main focus here, there is a
need to look at the soft tissue structures surrounding the teeth and
intraoral structures. The term “orofacial” is used to remind you to look
at more than just the intraoral structures and function. Make notes on
facial structures and symmetry both at rest and in speech function, as
presented later. The likelihood of your finding anything of significance
is low, but missing asymmetry of muscular function could have a
negative impact on the accuracy of your findings and possibly on your
treatment plan. On the other hand, a child may have rather remarkable
facial asymmetry that does not affect speech at all. This is often the case
in hemifacial microsomia, a condition with a very wide range of
severity and an even wider range of causes (OMIM #164210). If you find
asymmetry in the size or shape or facial muscle movement in a
youngster, discuss your findings with the parents to find out what they
already know, or may be ready to explore, if you are the first
professional to talk with them about it.
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Categories of the Observations to Be
Made
The amount of time you can take to pay aention to each of the
structures (and relationships between structures) listed here will
depend on your professional seing, on your experience, and also on
what you suspect the problems to be in a given child. In the typical
school seing, you may not need or have time to investigate in detail
each of the points discussed here.
Nasal Form, Symmetry, and Scarring
In children with repaired clefts of the lip and palate, you may see
flaening of one or both nasal alae due to the lack of normal cartilage
support. Another cause for this flaening is deficiency in the length of
the columella. (In infants with bilateral clefts, the dome of the nose can
be directly aached to the medial segment of the lip, with no columella
at all [see Chapter 1]). Although a flaened nose is a rather poor
cosmetic result and the parents will be unhappy about it, it typically has
no functional effect.
Lips
1. Lip competency: Rarely, a cleft lip may be so poorly repaired that it is
still anchored to the premaxilla, with lile to no nasal columella, as seen
in Figure 7-1. This lip is also deficient in length, and the protrusive
premaxilla makes bilabial closure difficult. This is an extreme case,
however. A repaired lip that is deficient in length may result in
dentalized bilabials (i.e., lower lip articulates with anterior maxillary
teeth). From the listener's standpoint, however, this type of production
on bilabial targets is more visually than auditorily distracting (i.e., if
you are not looking at the speaker, you perceive a “normal” bilabial, but
if you are looking at the speaker, the visual percept can be confusing).
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FIGURE 7-1 A badly scarred and poorly repaired,
foreshortened lip in a youngster with a bilateral cleft, with the
additional problem of a protrusive premaxilla, both problems
predisposing toward lip incompetency.
2. Symmetry on lip retraction, pursing, rounding, compressing (these
are all movements requisite to normal articulation): As stated in
Chapter 3, “bunching” on lip rounding is a sign of failure to align the
fibers of the orbicularis oris properly at the time of lip repair (see
Chapter 3, Fig. 3-5).
3. Scarring that may affect lip mobility: Upper lip scarring may reduce
lip spreading/retraction as in “ee” or rounding for “oo” and “o.”
Clearly, the patient seen in Figure 7-1 could have problems of this type.
4. Check the lower lip (including the interior surface) for pits or mounds
as shown in Figure 7-2. Although these have no functional significance,
they are an important indicator of the presence of a multianomaly
syndrome (also see Chapter 13).
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FIGURE 7-2 Bilateral lip mounds (with pits) in a case of van der
Woude syndrome. This woman did not have a cleft, but her baby
had both lip pits and a complete unilateral cleft lip and palate.
Tongue (See Figure 7-3 to review intraoral surface
anatomy.)
1. Check for any structural differences in the tongue body (e.g.,
macroglossia, microglossia) or lingual frenulum. Figures 7-4, 7-5, and 7-
6 show different presentations of “ankyloglossia,” which literally means
“anchoring of the tongue” by a lingual frenulum that is too short,
anteriorly displaced, or both. But be careful about over-interpretation
regarding the impact on articulation.
Clinicians are often in disagreement about just how short a lingual
frenulum has to be to affect speech. Some say there is no cause to worry
if the tongue tip can extend over the lower teeth or reach the maxillary
alveolar ridge when the anterior maxillary and mandibular teeth are
apart by X number of millimeters. Others point out that the tongue tip
does not really have to extend beyond the lingual surface of the teeth,
even for interdentals. It seems best to explore the ability of each child
with a supposed “tongue-tie” to see just what he or she can do in
speech sound production. (For further reading, see Kummer, 2005.)
2. Assess the child's ability to point the tongue and protrude it in
midline and elevate the tip to the alveolar ridge. Also assess
lateralization to labial corners for range and symmetry of movement.
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FIGURE 7-3 Anatomic structures of the oral cavity. (From Seidel H,
Ball JW, Dains JE, Benedict GW: Mosby's guide to physical examination [ed 6]. St.
Louis: Mosby, 2006.)
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FIGURE 7-4 The lingual frenulum is too short and attached too
far anteriorly to the floor of the mouth. This may or may not
cause articulation problems. (From Trost-Cardamone JE: Structural organic
disorders of speech: graduate course, California State University at Northridge,
Northridge, CA.)
FIGURE 7-5 The lingual frenulum in this youngster is attached
at the very tip of his tongue. Tongue elevation is restricted,
especially of the tip. Note the resulting heart shape of the anterior
lingual margin. (From Trost-Cardamone JE: Structural organic disorders of
speech: graduate course, California State University at Northridge, Northridge, CA.)
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FIGURE 7-6 Heart-shaped replacement of tongue tip on
protrusion, a sign of ankyloglossia. (From Trost-Cardamone JE: Structural
organic disorders of speech: graduate course, California State University at Northridge,
Northridge, CA.)
Dentition
1. Missing teeth, rotated or malpositioned teeth (including “ectopically
erupted” teeth, meaning teeth that have erupted in an abnormal place),
and extra (supernumerary) teeth are dental deviations that are
frequently seen in children with cleft lip and palate, but also are seen in
children with no cleft. Missing teeth are also a frequent finding in
youngsters with cleft palate only. It is common for children with
unilateral or bilateral clefts to be missing lateral incisors. When the
lateral incisors are present, they may erupt ectopically. Figure 7-7 shows
ectopic lateral incisors in two different youngsters.
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