The Role of the Speech and Language Therapist in the Cleft Team

Sue Mildinhall Lead Speech and Language Therapist South Thames Cleft Service Guys and St Thomas NHS Trust, London, England

South Thames Cleft Clinics

Outcomes of cleft palate surgery

Speech Appearance & Growth
Psychological well-being

Plan
1.To describe the work of the Speech and Language Therapist in the cleft team 2.To discuss speech difficulties associated with cleft palate 3. To describe how we manage the speech problems of the child with cleft palate

Aim of the Team

To ensure best possible speech outcome for child born with cleft palate as early in life as possible

The work of the Speech and Language Therapist (SLT)

Monitor speech development and speech outcomes in relation to cleft Provide differential diagnosis for cleft/non cleft speech problems Advise surgeon when VPI suspected & about all slt issues Participate in multi-disciplinary clinic Speech assessments & palate investigations Teaching Liaise with local SLT or family about treatment strategies Provide therapy to local or challenging cases

How do we do this?
Early speech and language development advice Speech assessments at regular intervals Therapy as needed Regular joint clinics with surgeons

Regular feedback to surgeons on outcomes

How do we speak ?
We speak on exhaled air Voice is produced by the larynx The soft palate lifts to close off the nasal cavity We shape the air with lips & tongue to make different sounds Sequence into words & sentences

Why is the soft palate important?

Romanian has 20 consonants English 24 consonants Only 2 are nasals n m All the others are oral & are produced with a raised soft palate Closure is particularly important for the sounds requiring a build up of oral pressure

key

Types of speech problems

May sound nasal Sounds may be mispronounced/omitted

Nasal consonants (m n ng) should be possible Oral consonants (pb td kg s f sh ch) are vulnerable

What might cause the problem?

Soft Palate may not work effectively Fistulae Orthodontic problems Malocclusion Fluctuating Hearing Loss

What do we assess?
1. Intelligibility can we understand the child? 2. Airflow problems -balance of air resonating in oral/nasal cavities? Nasal emission of air? 3. Articulation are sounds produced correctly?

Intelligibility
How difficult is it to understand the child according to; 1. The parent/carer 2. School/Nursery 3. Unfamiliar adults 4. The SLT?
What is the reason for the poor intelligibility?

Airflow Problems Hypernasal resonance

Too much air resonates in the nasal cavity
Oral consonants can sound nasalised Or become nasal eg b=m

Suspected velopharyngeal insufficiency (VPI/VPD)

Airflow Problems - Audible Nasal Emission

Audible air escape from the nose Heard accompanying sounds eg p, t, k, s, f

? Fistula or VPI

2. Articulation
Cleft-type speech patterns:
1. 2. 3. 4. 5. 6. 7. 8. 9. 10. Lateralisation Palatalisation Backing to velar Backing to uvular Pharyngeal Glottal Active Nasal Fricatives Weak nasalised consonants Nasal realisations Absent pressure consonants
(GOS.SPASS 1998)

Who will need speech therapy?

50% 5 year olds more or less normal speech 81% 12 year olds
(CSAG 1998)

Prediction of cases impossible 25 - 30% will need further surgery for speech (CSAG 1998, Mildinhall et al 2007)

The skill of therapy

Recognise when children are ready/not for therapy
- What needs therapy and what needs surgery - Provide therapy in a timely and fun way - Work with families, giving them the skills to - continue work at home - Adapt therapy style according to childs needs

Why investigate?
Perceptual speech assessment indicates characteristics of VPI Objective investigation required to inform further management Oral examination alone inadequate Videofluroscopy shows us the structure.length, stretch of the soft palate during speech Nasendoscopy shows sphincter from above Leads to treatment plan

Speech Surgery after investigation

Palate re repair Pharyngoplasty Posterior pharyngeal wall implant

John Boorman Norma Timoney

Summary
Speech and Language Therapists role in assessment, diagnosis, therapy Speech difficulties associated with cleft / VPI Principles of speech assessment Good practice in the speech management of children with cleft palate and VPD Importance of a Team approach

Team work
Surgeons, dentists, specialist nurses, Speech and Language Therapists, psychologists, audiologists collaborate in the care of the child with cleft throughout childhood