Evaluation and Treatment of Speech/Resonance Disorders And

Treatment of Speech/Resonance Disorders Associated with Velopharyngeal Dysfunction

Ann W. Kummer, PhD, CCC-SLP, FASHA

Division of Speech-Language Pathology Financial Disclosures Royalties: • Book: Kummer, AW. Cleft Palate and Craniofacial Conditions: A Comprehensive Guide to Clinical Management, 4th edition. Jones & Bartlett Learning, 2020. • Clinical Device: Oral and Nasal Listener (ONL), Super Duper Publications (Patent: Nasoscope)

Division of Speech-Language Pathology Financial Disclosures

• Honoraria: I receive honoraria for seminars on cleft palate, craniofacial anomalies, resonance disorders, and velopharyngeal dysfunction • Consulting: I receive payment for consulting on business practices of speech-language pathology programs

Division of Speech-Language Pathology Course Chapters

1. Physical management 2. Speech therapy techniques 3. Speech therapy carryover

Division of Speech-Language Pathology Physical Management

Division of Speech-Language Pathology Treatment of VPI • Surgery • Prosthetic device, if surgery is not an option • Speech therapy postoperatively for compensatory articulation errors

Division of Speech-Language Pathology Treatment of VP Mislearning • Speech therapy only

Division of Speech-Language Pathology Surgery for VPI

• Pharyngeal augmentation • Furlow Z-plasty • Pharyngeal flap • Sphincter pharyngoplasty

Note: These do not always work the first time. Child may need revision or even re-do.

Division of Speech-Language Pathology Pharyngeal Augmentation

• Injection of a substance (i.e., fat, collagen, Deflux, etc.) in the posterior pharyngeal wall • Appropriate for small, localized gaps

Division of Speech-Language Pathology Furlow Z-Plasty • Z incisions are made in the velum and flaps are overlapped to lengthen it • Used as an initial cleft palate repair or secondary repair for VPI • Appropriate for narrow, coronal gaps

Division of Speech-Language Pathology Pharyngeal Flap • Flap is taken from the posterior pharyngeal wall and sutured into the velum • Forms a midline “bridge” with lateral ports on each side for nasal breathing • Appropriate for central openings (e.g., cleft palate, post-adenoidectomy, etc.), big openings, or deep gaps

Division of Speech-Language Pathology Pharyngeal Flap

Division of Speech-Language Pathology Sphincter Pharyngoplasty

• Posterior faucial pillars (with palatopharyngeus muscles) are excised at the base and sutures into the posterior pharyngeal wall • Appropriate for lateral gaps (e.g., with hemifacial microsomia)

Division of Speech-Language Pathology Sphincter Pharyngoplasty

Division of Speech-Language Pathology Factors in Procedure Selection

• Cause: irregular adenoids versus short velum • Size of the opening • Risk of airway obstruction • Location, Location, Location!!! Need to find the hole and find the right procedure to fill it!

Division of Speech-Language Pathology Prosthetic Devices

• Palatal obturator • Speech bulb obturator • Palatal lift

Division of Speech-Language Pathology Palatal Obturator

• To occlude an open cleft or symptomatic oronasal (palatal) fistula

Division of Speech-Language Pathology Speech Bulb Obturator • To occlude the nasopharynx • Used for a short velum (VP insufficiency)

Division of Speech-Language Pathology Speech Bulb Obturator

Division of Speech-Language Pathology Palatal Obturator and Speech Bulb Obturator

• Occludes a fistula or open cleft • Occludes the nasopharynx

Division of Speech-Language Pathology Palatal Lift • To hold the velum up in place against the posterior pharyngeal wall • Used for poor velar movement (VP incompetence), as with dysarthria

Division of Speech-Language Pathology Prosthetic Devices • Used if surgery is not an option • Can be expensive and not covered by insurance • Has to be adjusted periodically, esp. for kids • Can be lost or damaged • Requires insertion and removal • May be uncomfortable • Compliance is often poor • Doesn’t permanently correct the problem

Division of Speech-Language Pathology 2. Speech Therapy

Division of Speech-Language Pathology Purpose of Speech Therapy

• To correct abnormal articulation placement for specific speech sounds

Division of Speech-Language Pathology Purpose of Speech Therapy

• Speech therapy CANNOT correct obligatory distortions (where placement is normal) • Speech therapy CAN correct: • compensatory errors after correction of the structure • placement errors that are “mislearned” and cause nasal emission or hypernasality

Division of Speech-Language Pathology Speech Therapy Techniques

Division of Speech-Language Pathology Speech Therapy with Uncorrected VPI

•Exercises do not work!!!

Division of Speech-Language Pathology Speech Therapy with Uncorrected VPI • Done while waiting for surgery or a prosthesis • Use nose plugging • Provides oral pressure to work on articulation

Division of Speech-Language Pathology Speech Therapy with Uncorrected VPI • Nose plug is best for therapy • Child should wear nose plug at home as much as possible • Swimmer’s nose plug can be purchased online

Division of Speech-Language Pathology Speech Therapy after VPI Surgery

• Changing structure does not change function • Nasal emission may be due to compensatory productions • Hypernasality may be due to a lack of lateral wall motion

Division of Speech-Language Pathology Speech Therapy after VPI Surgery • Straws or listening tubes work best

Division of Speech-Language Pathology Video: Listening Tube for Feedback

Division of Speech-Language Pathology Disadvantage of Listening Tube

• SLP (or parent) can’t hear what child hears • Half of the sound is going through the tube to the child’s ear

Division of Speech-Language Pathology Oral & Nasal Listener (ONL)*

* Super Duper Publications - 2007

Division of Speech-Language Pathology Oral & Nasal Listener (ONL)* • Allows the SLP (or parent) to hear the sound give feedback

* Super Duper Publications - 2007

Division of Speech-Language Pathology Oral & Nasal Listener (ONL)* • Gives feedback regarding oral airflow and oral speech sound production

* Super Duper Publications - 2007

Division of Speech-Language Pathology Therapy for Placement Errors

• Glottal stops • Nasalized vowels or ŋ/l • Nasalized (or misarticulated) /r/ • Pharyngeal plosives (or abnormal k/g) • Pharyngeal (or posterior nasal) fricatives • Palatal-dorsal production (or lateral lisp)

Division of Speech-Language Pathology Start with Sensory Awareness • Make the child aware of the wrong sound versus the target (correct) sound • Give as many clues as possible using the following senses: • Visual awareness: Watch it • Tactile awareness: Feel it • Auditory awareness: Hear it

Division of Speech-Language Pathology Therapy for Glottal Stops

• Watch the neck in mirror during production • Feel the neck during production • Hear the difference • Contrast glottal stop with nasal syllables (i.e., ma) • Contrast the glottal stop with the target sound

Division of Speech-Language Pathology Therapy for Glottal Stops

• Reverse roles: Have the child be the “teacher” and you be the kid

Division of Speech-Language Pathology Therapy for Glottal Stops

• Start with isolated voiceless plosive (/p/) • Combine with vowel preceded by an /h/ (/p…hɑ/) • Produce the /b/ with a whisper and slow transition to /h/ before the vowel (/b…hɑ/)

Division of Speech-Language Pathology Therapy for ŋ/l or nasalized vowels

• Begin with a big yawn to raise the velum and bring down the back of the tongue • Make the child aware of the stretch in the back of the mouth • Co-articulate the yawn with an /l/ or vowel

Division of Speech-Language Pathology Therapy for ŋ/l or nasalized vowels

• Use the ONL or listening tube for feedback • Have the child close and open the nose for feedback

Division of Speech-Language Pathology Video: Yawn Technique for /l/

Division of Speech-Language Pathology Normal Articulation for /ɚ/ and /r/

• Produced by the back of the tongue, not in the front • /ɚ/ is a continuant sound • /r/ is a movement sound

Division of Speech-Language Pathology Video: Nasalized (or Misarticulated) /ɚ/

Division of Speech-Language Pathology Therapy for /ɚ/

• Show how the shape of the tongue forms a “boat” • Show where the back of tongue touches gum ridge under the upper molars

Division of Speech-Language Pathology Therapy for /ɚ/ • Stimulate back of the tongue on each side, and then the gum ridge under the molars

Division of Speech-Language Pathology Therapy for /ɚ/

• Tell the child to make a wide smile and then “back up the boat”

Division of Speech-Language Pathology Therapy for /ɚ/ • Push up against the base of the chin with your finger to push up the back of the tongue • Make sure it feels loose so you can push

Division of Speech-Language Pathology Therapy for /ɚ/ • Squeeze the cheeks with your thumb and forefinger to get lip rounding • Use your middle finger to push up the back of the tongue

Division of Speech-Language Pathology Video: Therapy for /ɚ/

Division of Speech-Language Pathology Therapy for /r/

• Once final /ɚ/ is achieved, work on initial /r/ • Start with /ɚ/ and show the forward movement of the tongue with your hand • Have the child “push the boat forward”

Division of Speech-Language Pathology Therapy for /r/

• Have the child hold his hands on his face. Tell him to go from /ɚ/ to /r/ without moving his face

Division of Speech-Language Pathology Therapy for Pharyngeal Plosives (or abnormal k/g)

• Start with an /ŋ/ placement • Have the child hold /ŋ/ to feel placement

Division of Speech-Language Pathology Therapy for Pharyngeal plosives (or abnormal k/g)

• If the child can’t produce an /ŋ/… • Put a tongue blade on the middle of the tongue and push down and back firmly OR • Firmly press your thumb under the base of the child’s chin to push the back of the tongue up

Division of Speech-Language Pathology Therapy for Pharyngeal plosives (or abnormal k/g)

• Have the child achieve the position and then drop the tongue to get the up and down movement • Add the vowel

Division of Speech-Language Pathology Therapy for pharyngeal plosives (or abnormal k/g)

• Have child take a breath, place his tongue in an /ŋ/ position, and push to produce a /g/ OR • Have the child produce /ŋa/ with the nose closed • Have the child whisper the sound for the /k/

Division of Speech-Language Pathology Video: Therapy for k/g

Division of Speech-Language Pathology Therapy for Phoneme-Specific Nasal Emission (PSNE)

• PSNE is due to the use of either a pharyngeal fricative or posterior nasal fricative • Correcting placement eliminates the phoneme-specific nasal emission (PSNE)

Division of Speech-Language Pathology Therapy for PSNE

• Have the child produce a /t/ sound • Have him produce a /t/ sound with the teeth closed • Have the child prolong the production until it becomes /tssss/

Division of Speech-Language Pathology Video: Therapy for PSNE

Division of Speech-Language Pathology Video: Therapy for PSNE • Therapy to transition from /tssss/ to the vowel

Division of Speech-Language Pathology Video: Therapy for PSNE

• Use a straw to provide feedback

Division of Speech-Language Pathology Therapy for a Lateral Lisp • A lateral lisp is occurs when the tongue touches the teeth, alveolar ridge or palate, thus blocking the anterior emission of the airstream. • Lateral lisp occur primarily on sibilants, but can occur on lingual- alveolar sounds if there is a delay in the lingual release.

Division of Speech-Language Pathology Therapy for Lateral Lisp • To determine where there is airflow, put a straw in front of the teeth and then to the sides during the production of the /s/

Division of Speech-Language Pathology Therapy for Lateral Lisp

• If normal, air will be heard through straw when it is in front of the central incisors • If lateral, air will be heard through straw when it is at the side of the dental arch

Division of Speech-Language Pathology Therapy for Lateral Lisp • Same technique as with pharyngeal fricatives • Have the child produce /t/ and push the airstream into the straw • Have the child produce /tsss/ and push the airstream into the straw • Transition to the syllable by inserting an /h/ between the /s/ and vowel

Division of Speech-Language Pathology 3. Carryover

Division of Speech-Language Pathology Establishment of “Carry-Over”

• Speech requires motor movement that is fast, complex, automatic and effortless • This is accomplished by motor learning and motor memory

Division of Speech-Language Pathology Motor Learning

• Motor learning: Acquisition of new motor skills in order to execute complex motor movements and sequences • Motor learning is dependent on: • Instructions • Trial and error • Feedback

Division of Speech-Language Pathology Motor Learning

• Results in the development, change or refinement of the speech sound production • Motor learning is what occurs in speech therapy when the SLP teaches placement and provides feedback

Division of Speech-Language Pathology Motor Memory

Motor memory: Develops automaticity of the newly learned motor movement • Dependent on constant repetition (e.g., practice) • Drill work is important

Division of Speech-Language Pathology Motor Memory through Practice • Results in brain reorganization due to neural plasticity • Allows movement to be done without conscious thought • Makes new learning permanent • Results in “carry-over” into connected speech • Requires frequent, daily practice at home

Division of Speech-Language Pathology Motor Memory through Practice

• Necessary for all complicated motor movements and sequences without conscious thought, such as: • Ballroom dancing • Sports • Playing a musical instrument • Speech

Division of Speech-Language Pathology Therapy is like Piano Lessons

• Speech therapy is like taking piano lessons—if you just go for the lesson, but don’t practice at home, you don’t learn to play the piano!

Division of Speech-Language Pathology Family as Part of the Treatment Team • Need to train the parents/family members to work with the patient at home

Division of Speech-Language Pathology Practice Frequency • Frequent sessions should be done at home throughout each day. • Practice sessions can be a short (a few minutes at a time) but should include drill work for motor memory.

Division of Speech-Language Pathology Practice Intensity

• Dose: Number of correct responses in a practice session (in therapy or at home) • Higher dose per practice session is directly related to the rate of progress • Drill work is most effective

Division of Speech-Language Pathology Practice Intensity • Use tokens and work quickly

Division of Speech-Language Pathology Practice Distribution

• Distributed practice (practice throughout the week) facilitates short-term performance and long-term learning

Division of Speech-Language Pathology Weekly Practice Log

Child’s Name: ______Start Date: ______

W Mon Tues e Thurs Fri Sat Sun Total d

# of times W Mon Tues e Thurs Fri Sat Sun Total d # of times W Mon Tues e Thurs Fri Sat Sun Total d # of times W Mon Tues e Thurs Fri Sat Sun Total d # of times

Division of Speech-Language Pathology Language Learning Same principles apply to language learning • Learning a second language requires instruction • Becoming fluent requires study and practice, which should be done outside the lesson • Language therapy is the same Como esta usted?

Division of Speech-Language Pathology Goal of Treatment • Goal of treatment: • Normal speech (no nasal emission) • Normal resonance (no hypernasality or hyponasality)