Picture this. You’ve just been referred your first child with a repaired cleft palate. They’re 7 years old, their speech is unintelligible, and you’re wondering where to go next. Should I even be treating this child? Don’t they need surgery before I can start therapy? What was that sound they just made? How complex is their course of care with the cleft team? Am I supposed to talk with their cleft team? What am I even looking at in their mouth? And why is that tooth there?

Sound familiar? If you’ve had any of these questions, you’re in the right place! Let’s dig into some of the research on the basics of where to start when a child with a cleft appears on your caseload.

Understanding cleft palate and its impact on speech

In the United States, approximately 1 in every 1,000 children are born with a cleft and many will develop speech problems after their first surgical repair. This is because clefting affects the velopharyngeal (VP) mechanism, aka the speech/resonance mechanism. Most often this means that, even after the palate is repaired, a child will continue to be hypernasal (sounding like they are talking through the nose) or will develop compensatory misarticulations (distortions and/or substitutions of their speech sounds) which makes it harder to be understood. Usually, it’s a combination of both.

Key takeaway: It is really common for children born with cleft conditions to have speech problems at some point. Over half of these children will need speech therapy; however, most will develop normal speech by age 5 with the appropriate team care and supports in place. If you need a quick refresher on the basics of clefting, you can refer to the American Cleft Palate Craniofacial Association’s Resource Center and handbook or the ASHA Practice Portal.

How does the VP mechanism work?

AKA the section you’re tempted to skip over because it sounds tedious, but you shouldn’t because it’s fundamental to the whole shebang!

The VP mechanism regulates airflow and sound between the nasopharynx (the area behind the nose) and the oropharynx (the area behind the mouth). The best analogy for how it works is to think of it as a door, with the soft palate being the door and VP space being the door jamb. 

• When the door is open, air can move from the lungs, up the vocal tract, and out through the nose. We need this door to be open for nasal breathing and to produce nasal consonants.
• When the door is closed, airflow and oral pressure can be created to direct consonants out of the mouth.
  • The door also needs to be closed for swallowing so food and liquid can’t escape through the nose.
• Sometimes the door has a problem: It's wide open (like in an unrepaired cleft palate or immobile soft palate), too small (like after a failed cleft repair), or maybe the doorway is too big (like we see in a lot of congenital craniofacial syndromes).

This is a great analogy for explaining this complex anatomy to your patients and their caregivers. For a more detailed analysis of the mechanism, you can check out this review article. A printable version of the “door” analogy is included in this review's clinical resources—download here. 

Key takeaway: Normal speech and resonance rely on the coordinated movements of the VP anatomy: the soft palate or velum, the posterior and lateral pharyngeal walls, and the muscles within them. These structures work together to control the opening and closing of the "door" and modulate the airflow between the nasopharynx and oropharynx based on the specific needs of the activity being performed.

What if the VP mechanism isn’t doing what it’s supposed to do?

This is known as velopharyngeal dysfunction (VPD). We can categorize disorders related to velopharyngeal dysfunction as disorders of nasal airflow and disorders of resonance, each of which can have an impact on speech production and intelligibility. We perceive disorders of nasal airflow on voiceless sounds and disorders of resonance on voiced sounds.

VPD can arise due to cleft or non-cleft-related conditions and can be further separated based on etiology with the acronyms VPI… or VPI… or VPM. 

Wait… what? Three different kinds of VPD with basically the same acronym? Yup! 

1. Velopharyngeal Insufficiency: Arises due to structural causes and post-surgical tissue insufficiencies, e.g. cleft palate.
2. Velopharyngeal Incompetence: Arises due to neurogenic causes, like apraxia or dysarthria.
3. Velopharyngeal Mislearning: Arises due to learned articulatory or resonance patterns, like phoneme-specific nasal air emission or hypernasality due to deafness/hearing impairment. In these cases, the VP anatomy is functional, despite the errors being produced.

Because of these nuances, we need to be specific about the terms we use and make sure we know the etiology of the specific case of VPD we’re working with—getting a thorough case history and doing a solid assessment is helpful here.

This is important because treatment options for each type of VPD look very different. Sometimes it’s managed with surgery, sometimes it’s therapeutic, sometimes it’s both! Sometimes it’s nothing! For this piece, we’ll be focusing on velopharyngeal insufficiency (VPI) secondary to cleft palate from this point forward. 

How is VPI repaired?

The first repair in patients with a cleft palate is called palatoplasty. Unfortunately, surgical outcomes have a long way to go because approximately 20–38% of primary palatoplasty surgeries fail, meaning approximately 1/3 of children with repaired cleft palate develop VPI. Any additional surgeries to the palate to improve resonance are typically called palatoplasty revisions (a re-do or another version of the first palate surgery) or a pharyngoplasty (where tissue is borrowed from another area in the naso/velopharynx).

What are the symptoms of a VPI?

The most common speech features (known as cleft speech characteristics or CSCs) are: 

1. Speech sound substitutions
2. Hypernasality
3. Reduced oral pressure
4. Nasal air emission

These CSCs and the other symptoms associated with VPI can be either active or passive. Passive errors are usually eliminated by surgery, but active errors are not. 

Tell me more about those active vs. passive speech errors 

Differentiating between active and passive errors is the foundation to identify which cleft-related speech characteristics are most likely to respond to surgical intervention or speech therapy. This is the information you will use to determine your treatment plan.

Active speech errors are compensatory misarticulations (speech sound substitutions) that the child has learned, often because of the VPI. These learned errors will persist because the child has established a maladaptive articulatory pattern and/or phonological system for these phonemes. These include non-oral substitutions for oral speech sounds. The place of articulation is altered, but the manner is retained, and oral pressure consonant targets become glottal articulations, pharyngeal articulations, and/or nasal fricatives. These are the errors we can correct with speech therapy! Hooray!

In contrast, passive speech errors are the product of structural abnormality. In other words, these errors are caused by a physical problem with the articulatory or velopharyngeal mechanism (think palatal fistula, dental arch malformations, or velopharyngeal insufficiency). This is where hypernasality, weak or omitted pressure consonants, reduced utterance length, and obligatory nasal for oral sound substitutions come into play. These are the errors that surgery can eliminate.

What should my assessments include?

We have some fun options here. Admittedly, I’m using the term fun in a very general sense: it isn’t quite spa-day-with-your-besties fun, but it’s definitely more fun than taking the Praxis or sitting through marathon IEP meetings. The magic happens when your screenings and assessments for VPI are successful and you get clear answers for how to proceed with interventions and recommendations!

Before you get overwhelmed trying to remember all this info, remember that we put together a printable assessment guide for you that covers the VP mechanism, active vs. passive errors, plus an assessment outline and summary chart. Download it here!

Your screenings and assessments should include a behavioral and qualitative analysis of resonance (CPT 92524) to screen VP function and an assessment of speech sound production (CPT 92522) to examine the oral mechanism and assess articulation and intelligibility. These are important first steps because they can help you determine if the child might need to be seen by the team sooner than planned and can inform your road map for speech therapy.

We'll go into more detail about the major assessment components below. 

Key takeaway: In your assessment, you'll be answering three big questions: 

1. What are the child’s speech sound errors and how should they be classified?
2. What resonance quality is the child demonstrating (hypernasal, hyponasal, mixed) and is there any nasal air emission?
3. How do the findings from (1) and (2) correlate with what you saw in the oral exam?

I. Assessment of speech sound production and intelligibility

Be sure to document the phonetic inventory, note any phonological or developmental errors (standard articulation tests like the GFTA or DEAP are helpful for this), and rate the child’s overall intelligibility.

Knowing what phonemes the child can produce accurately will help with developing your therapy goals. If you want to take your assessment to the next level, you can also include a parent rating scale like the Intelligibility in Context Scale (ICS) and a quality-of-life measure like the CLEFT-Q, VELO (free), or CSQ.

Calculating Percent Consonants Correct (PCC) can give you an easy baseline measure for progress monitoring. As part of the Parent-Led Articulation Therapy study out of the UK, a form for tracking PCC outcomes and progress is included in this study.

II. Screening of VP function: Resonance and nasal air emission

Unfortunately, there’s limited consensus on the best speech samples and rating scales to use, but categorical, ordinal scales (like a scale from 0 to 3, or normal/mild/moderate/severe) are a go-to for assessing velopharyngeal function, nasal air emission, and articulation. You can derive these ratings from targeted informal sound/sentence repetition and conversational speech samples, or you can use standardized rating systems.

Either of these two standardized rating systems (which have corresponding speech sampling procedures) will give you a good starting point for assessing velopharyngeal function:

1. The Cleft-Audit Protocol for Speech- Augmented AMericleft Version (CAPS-A-AM). This study explains the process for completing ratings using the CAPS-A-AM in Table 1. The standardized speech sample is listed in Appendix A.
2. Pittsburgh Weighted Speech Scale. See Figure 1 of this study for a worksheet outlining each variable and rating category.

If you’re pressed for time and just need to collect some baseline data to facilitate a referral, you can rate speech using informal screening and sound/sentence repetition tasks. Here are some considerations based on suggestions from Kummer (2014) if you go in this direction:

Assessment of hypernasality:

• Assess in connected speech.
• Use oral-loaded sentences like pick up a puppy; buy baby a bib; take teddy a toy.
  • These oral consonants and vowels will sound hypernasal and the oral pressure consonants might sound more like their nasal cognates (i.e. /b/ sounds more like an /m/).
• Open and close the nares during sustained /i/
  • If  /i/ sounds different with nose open vs. nose closed, hypernasality is likely present.

Assessment of hyponasality:

• Assess in connected speech.
• Use nasal-loaded sentences like mama made lemonade or counting from 90 to 99.
  • These nasal consonants will sound “stuffy” and may sound like their oral cognates (i.e. /m/ sounds more like a /b/) if hyponasality is present.

Assessment of nasal air emission:

• Assess with sustained /s/, sibilant blends, or sentences loaded with sibilants, affricates, and fricatives like counting from 60 to 70, Susie sees sissy; she went shopping.
• You may be able to hear the nasal air emission if it is audible.
• A nasal grimace may indicate nasal air emission. If you see a nasal grimace, but do not hear nasal air emission, it may be inaudible. Use the See-Scape, a nasal mirror, or paper paddle under the nose to confirm. (A printable air paddle plus directions are included as a supplemental download in Part Two of this series!)
• If nasal air emission is happening with specific phonemes and not throughout connected speech, you may actually be hearing a nasal fricative! This is an active compensatory speech error and not passive nasal air emission.

III. Orofacial examination

Oral exams can only tell us what is going on in the oral cavity and how that impacts speech function. The findings can give us clues about what might be going on, but they can’t tell us what is specifically happening within the velopharyngeal mechanism. This is because we aren’t able to see what’s going on behind and above the oral cavity; imaging is needed for that piece. Even so, oral exams are important for children with CLP because they help to answer the underlying question: “Are the speech concerns due to anatomy (passive) or are they due to articulatory mislearning (active)?” 

Here are two example case studies: 

1. You're assessing a six-year-old and note some perceptually hypernasal resonance and nasal for oral sound substitutions during your conversational speech sample.

• On oral exam you see minimal palatal elevation on phonation, a tiny bifid uvula, notching on the posterior hard palate with an inverted “V” shape, and a zona pellucida.
• You suspect an undiagnosed submucous cleft is the culprit and are surprised no one has noticed this before.
• Based on your findings, you make a referral to the cleft team for further assessment.

2. During your annual speech assessments, you always do an oral exam. You notice a bifid uvula in a 9-year-old, but resonance is within normal limits and the only speech error this child has is a w/ɹ substitution.

• You document this oral exam finding and note that it does not appear to have a functional impact on speech or resonance.
• During the IEP meeting, you are asked if this is the reason for the speech difficulty or if there is a submucous cleft.
• You can confidently say that “No, an asymptomatic bifid uvula in isolation doesn’t always mean there is a submucous cleft. In fact, a large study of nearly 10,000 school-age children found that 100 kids had a bifid uvula. Of those, only 9 of the children with bifid uvula had SMC and most were also asymptomatic.”
• For more on SMC and a picture of what the signs and symptoms look like, you can check out this article.

Want to know even more? This review article (by yours truly) gives an overview of the impact that cleft-related dental anomalies have on speech production. 

Remember, you don’t need high-tech equipment to determine if there is a VPI. You can listen for pressure consonant production, use a straw or See-Scape to detect nasal air emission, and most importantly, your ear will guide you. Identifying if there is or isn’t velopharyngeal closure is the first step in facilitating a referral for comprehensive assessment and developing a treatment plan for the patient. 

When do I need to refer to the cleft team?

After you’ve identified the type of speech errors and the status of velopharyngeal function, you’ll need to determine if the errors are active (able to be remediated with speech therapy) or passive (need surgery). If the errors are passive (think hypernasality, nasal air emission, errors due to dentition), then the best course of action is to refer the child to their local cleft/craniofacial team for a full multidisciplinary assessment and imaging.

If the speech errors are active, then it’s time to dive into speech therapy! And remember, if you need help developing goals for therapy or think a more detailed assessment (like nasometry and imaging) is needed, consult with the child’s cleft team SLP.

What does a referral to the cleft team look like?

Each cleft/craniofacial team has someone designated as the team coordinator. If you don’t already have a relationship with the cleft team SLP, the team coordinator is your go-to contact for your referral. To locate the team coordinator for the nearest cleft team, go to the online ACPA-certified cleft/craniofacial team database.

With the consent of the family and contact information in hand, your referral to the cleft team should include a brief summary of:

• Relevant case history: Does the child have any relevant diagnoses, have they had any prior surgeries like an adenoidectomy, do they have recurrent ear infections, were there early feeding difficulties, etc.
• Reason for the referral: This is often related to a cleft or submucous cleft that hasn’t been previously assessed or managed by a team, a lapse in team care and need for updated annual team assessment, a plateau or little progress in speech therapy, and concerns that difficulties may be due to anatomy, or concerns of hypernasal speech without any signs of an obvious cleft.
• Assessment and screening results: Be sure to include your findings related to the child’s phonemic inventory and intelligibility, specific sounds that are impacted by any nasal air emission or hypernasality, and analysis of oral exam findings including function and the appearance of the hard and soft palate.
• Current speech therapy goals and progress to date, if applicable: What has the child been working on in speech therapy? What methods and tools are you using? How often is the child being seen?

With all of that ready to go, Dailey and Wilson (2015) outline tips for making referrals and communicating with the cleft team. They highlight that team care is a collaborative process and community-based providers are an important piece of the team. The cleft team SLP should be happy to answer any questions you have!

Key takeaway: Engaging in team care as a community-based provider typically looks something like this:

If you’ve made it this far, congrats! If you haven't already, make sure you grab the printable assessment outline and resources we've put together for you. 

When you're ready, click over to Part 2, where we’ll dive into the research on therapy methods for cleft-related speech errors!

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