CRANIOFACIAL Flashcards
define cleft
abnormal opening or fissure in an anatomical structure
what does a cleft often lead to
poor development of associated structures
cleft cause
usually congenital due to abnormal fusion of parts during development
where do clefts commonly occur
lip & palate
how common are orofacial clefts
most common congenital difference of the face in the world
2nd most common birth difference in US
4th most common birth difference in the world
subsystems of speech
respiration
phonation
resonance
articulation
prosody
what speech subsystems are most affected by cleft lip & palate
articulation
resonance (nasality)
pharynx
muscular tube connecting oral & nasal cavities to larynx & esophagus
adenoid tonsils
pharyngeal tonsil
may assist w/ vp closure due to location on posterior pharyngeal wall
involution prior to puberty
palatine tonsils (ones u usually get removed) & lingual tonsils (@ base of tongue)
contain lymphoid tissue & assist in fighting infection particularly from 0-2
prone to hypertrophy in younger children
atrophy almost completely by 16
hard palate
separates nasal cavity & oral cavity by bony plates
roof of mouth & floor of nasal cavity
alveolar ridge
front of hard palate
provides bony support for teeth
incisive foramen or fossa
hole or opening in hard palate to allow blood vessels & nerves to pass through
in alveolar ridge behind central incisors
starting point of embryological development
rugae
hard palate
ridges that run horizontally
incisive papilla
hard palate
projection of mucosa at area of incisive foramen
palatine raphe or suture
hard palate
line from incisive foramen to uvula
torus palatinus (palatine torus)
hard palate
normal structural variation
prominent longitudinal ridge on oral surface along median palatine raphe/suture
velum (soft palate)
consists of muscles & mucosa - no bone
attaches to posterior border of hard palate
uvula
tear drop structure at back of velum
consits of mucosa & tissue
very vascular - veins
no known function
palatine aponeurosis
thin fibrous sheet of connective tissue in back of hard palate
velopharyngeal valve function requires coordinated movement of what structures
velum
lateral pharyngeal walls
posterior pharyngeal wall
VP function - velum
velum in superior & posterior direction
“knee” action
moves toward posterior pharyngeal wall
VP function - lateral pharyngeal walls
moves medially
usually close against the velum
sometimes close in midline behind velum
VP function - posterior pharyngeal wall
moves anteriorly toward the velum
passavants ridge
bulge of muscles seen in PPW
what does the velum do
It closes off the nasal cavity when it raises
It prevents food and liquid from moving out the nose
It facilitates production of nasal and non-nasal sounds
role of VP in speech
valve that provides 3D closure of structures
closes off nasal cavity from oral cavity to regulate & direct transmission of sound energy & airflow in the oral & nasal cavities
what kind of sounds is VP important for
pressure sensitive consonants & all vowels
fricatives
VP function for oral sounds
VP valve is closed
allows acoustic energy to enter oral cavity
VP function for nasal sounds
VP valve open
allows most of sound energy to enter nasal cavity
T/F: VP valve must open & close quickly & efficiently
True
connection between Eustachian tube & velopharynx & differences in kids vs adults
connects ME w/ pharynx
at horizontal angle in children under 6 – kids more prone to ME infections
45 degree angle in adults
eustachian tube
pharyngeal opening is lateral & slightly above velum
craniofacial anomaly can affect ET function
levator veli palatini
elevates velum up & back
superior pharyngeal constrictor
move PPW anteriorly
LPWs medially
palatopharyngeus
constrict LPWs medially
don’t know exactly what it does still
palatoglossus
depresses velum
tensor veli palatine
opens ET
musculus uvulae
bulks uvula
what structures does a cleft lip affect
nasal ala rim - spreadng
columella - short
teeth - missing
alveolar ridge
lip
what functions affected w/ cleft lip
facial aesthetics / identity - stigma
specific articulation errors
resonance
structures affected w/ cleft palate
hard palate
uvula
soft palate - absent velar aponeurosis, LVP muscles insert into hard palate
functions affected w/ cleft palate
speech - resonance, hypernasality
articulation - impaired vowels & high pressure non nasal sounds
hearing - conductive HL, ET malfunction
early feeding - affects sucking, nasal regurgitation
velopharyngeal dysfunction (VPD)
generic term used to describe abnormal VP function regardless of the cause
profound speech & swallowing effects
cause of nasal resonance disorders
order of embryological development
- lip (primary palate)
6-8 weeks gestation - palate (secondary palate)
9-12 weeks gestation
development of each is independent
where does embryological closure begin
incisive foramen
zips forward to form alveolar ridge then lip
zips backward to form hard palate & velum
what is a cleft of the secondary palate
an opening in the palate behind the front teeth
complete cleft
didn’t start forming
incomplete cleft
started forming but didn’t finish
unilateral incomplete cleft lip
partial opening on one side of upper lip
unilateral complete cleft lip
full split from the lip to the nose on one side
bilateral incomplete cleft lip
partial splits on both sides of the lip
bilateral complete cleft lip
full splits on both sides of the lip
microform cleft lip
very small cleft
sometimes just a notch or line
simonart’s band
band of skin that crosses over a cleft lip
cleft palate
opening in the roof of the mouth
Pierre Robin sequence
condition w/ a small jaw, tongue falls back, & cleft palate
what does a repaired cleft lip & palate look like
scarring or reshaped lip/palate but closure is present
palatal fistula
hole between mouth & nose
often after surgery
submucous cleft palate
hidden cleft under the skin of the mouth’s rood
signs of submucous cleft
bfid uvula
bluish midline
notch in hard palate
can submucous clefts affect speech
yes if muscles are affected –> may cause resonance & speech issues
cul-de-sac resonance
sound gets “stuck” somewhere & sounds muffled
what is velopharyngeal dysfunction (VPD)
soft palate doesn’t close properly during speech
incompetence VPD
muscles don’t move well
neurological
insufficiency VPD
palate is too short
structural
mislearning VPD
speaker learned the wrong sounds placement
nasal emissions
air leaks through the nose on sounds like /p/, /t/, /s/
nasal turbulence
noisy airflow through a small nasal gap
sounds “rustly”
are nasal emissions always a problem
yes especially during pressure sounds
might need therapy or surgery
how can cleft palate affect speech & language
late babbling
fewer words
problems hearing & speaking clearly
speech can sound nasal or unclear
common surgeries for cleft
lip repair (2-6 mos)
palate repair (10-12 mos)
bone graft (8-9 yrs)
optional revisions or surgeries later
what are obligatory errors
mistakes caused by structure itself
therapy won’t help - surgery needed
compensatory (maladaptive) errors
child makes up new ways to produce sounds incorrectly
therapy can help after surgery
mislearning
incorrect speech patterns even after repair
therapy helps
how can we test for speech errors
surgery history
oral exam
trial therapy
plug nose & listen for changes
submucous cleft palate
type of cleft where the tissue (mucosa) looks intact –> but muscles underneath did not form correctly
2 types of submucous cleft palate
overt - visible from the mouth
occult - hidden , only visible from nasal side
function of levator veli palatini
pulls velum up & back to close off the nose during swallowing & speech
fuction of musculus uvulae
shortens & lifts uvula to help seal nose during speech & swallowing
function of tensor veli palatini
opens ET to help drain middle ear & equalize pressure
not important for VP closure
classic triad of submucous cleft
bifid (split) or tiny uvula
zona Pellucidar - bluish midline on soft palate
notch in hard palate
muscles of veau
misplaced levator muscles inserting in the wrong spot (hard palate)
creating a tent-like shape during speech
effects of submucous cleft
may cause no issues & resemble full cleft
VP insufficiency
nasal regurgitation
ET issues
when might a submucous cleft become symptomatic
after an adenoidectomy
removal of adenoids
how do we change resonance
opening or closing VP port
resonance disorder
when sound energy flows abnormally through the mouth, nose, or throat
types of resonance disorders
hyper/hyponasality
cul-de-sac
assimilative
mixed
what causes hypernasality
incomplete VP closure
too much nasal resonance
what causes hyponasaltiy
blocked nasal passages / inability to open VP during nasal sounds
mixed resonance
combo of hyper/hyponasality &/or cul-de-sac resonance
what is VPD
any issue where the soft palate doesn’t close the nose properly
nasal rustle
rustling sound due to small gap in VP closure
impact of cleft palate on speech
delayed speech
compensatory errors
nasal sounding voice
who’s on the multidisciplinary cleft team
plastic surgeon
ENT
SLP
AuD
dentist
social worker
nutritionist
genetic counselor
SLP’s role on cleft team
early feeding / speech support
evaluations
therapy
education
nasendoscopy guidance
what is AuD’s role
hearing screenings
managing ear infections
providing hearing aids if needed
supporting school services
at what gestational age can suckle & swallow sustain nutritional needs
by 34 weeks gestatioin
why is feeding important beyond nutrition
provides oral sensorimotor stimulation
supports state regulation
offers comfort & bonding
contributes to caregiver confidence
what factors support successful feeding
stable state regulation
hunger cues
vital signs
intact anatomy
suck-swallow-breathe coordination
airway protection
adequate intake
what are consequences of poor suck-swallow-breathe coordination
fatigue
poor intake
airway compromise
oxygen desaturation
distoress
negative feeding experiences
how does infant anatomy support feeding differently from adults
smaller mandible
high larynx
sucking pads
epiglottis touches velum
what happens during the oral phase of infant feeding
rooting reflex triggers latch
tongue movement & jaw drop create suction to extract milk from nipple
what protects airway during the pharyngeal phase
VF adduction & epiglottis retroflexion over the larynx
what happens during the esophageal phase
UES opens
bolus travels through the esophagus
LES opens to allow passage into the stomach
can infants w/ only cleft lip breastfeed
yes
w/ little difficulty
upright positioning & broad based nipples help
why can’t infants w/ cleft palate breastfeed effectively
cannot generate negative pressure needed for suction
SLP role in feeding therapy w/ cleft
prenatal counseling
feeding eval
therapy & modifications
pre/post operative support
how does prenatal counseling help
reduces NICU admissions for feeding issues
supports caregiver confidence & emotional health
caregiver challenges w/ cleft feeding
lack of professional support
overwhelming emotional responses to diagnosis & feeding difficulties
4 specialty bottles for cleft
pigeon
mead johnson
Dr browns specialty – one way valve to prevent backflow
medela
important bottle characteristics for cleft
no suction required
manageable
safe
supports skill development
delivers adequate milk volume
key feeding recommendations for cleft
specialized bottles
upright or side laying position
frequent burping
pacing
monitor for distress
what does SLP look for during feeding eval
positioning
pulsing
pacing
flow rate
distress cues
aspiration signs
distress cues during feeding
raised eyebrows
splayed hands
turning away
rigidity
arching
rapid sucking
no breathing
common feeding modifications
swaddling
changing nipples / positions
pacing
further eval (SLP or medical)
interventions that support better feeding
correct bottle use
altering flow rate
external pacing
swaddling
medical/SLP follow up
how can infants w/ cleft palate benefit from breastfeeding
through skin to skin contact
expressed milk
non-nutritive sucking
alternating deeding sides
normal feeding & weight gain expectations
return to birth weight in 2 weeks
<30 min feedings
1-2oz every 2-3 hours
90-120 cal/kg/day
signs infant is ready to feed
alertness
rooting
sucking on hands / objects
how to help infant show feeding readiness
pacifier
swaddle
bounce gently
change diaper to rouse if sleepy
when should feeding strategies be modified
if energy is wasted
reflux occurs
hunger cues/weight gain are lacking
when are feeding tubes considered
when oral feeding isn’t sufficient
what should be expected of infants w/ cleft but no other issues
efficient feeding & weight gain w/ special bottles
otherwise –> further eval needed
when to start open cup drinking
6-9 months
when should solids be introduced
6 months
if baby sits unsupported, shows interest, & doesn’t gag
nasal regurgitation is okay
which speech sounds require full VP closure & are impacted by cleft palate
plosives, fricatives, affricates
what is phoneme specific nasal emission (PSNE) & what causes it
PSNE is nasal emission occurring only on certain phonemes
caused by mislearning
obligatory productions
happen when the structure is the problem, but placement is correct
will speech therapy help obligatory productions
no
compensatory production
learned adaptations due to structural deficits
pharyngeal stops/fricatives, glottal stops
when should speech/resonance be evaluated in children w/ clefting
between ages 3-5
when the child can:
produce connected speech
cooperate for testing
have an airway big enough for surgery
purpose of orofacial exam
identify structural anomalies
determine whether the issue is obligatory, compensatory, or mislearning
is further evaluation needed
structures examined during an orofacial exam
tongue
palatine tonsils
oral surface of velum/uvula
alveolar ridge
hard palate
teeth
visual tasks in resonance assessment
observe airflow
dental mirror
auditory tasks in resonance assessment
plug nostrils
listen for changes w/ straw to nose test
tactile tasks used in resonance assessment
feel for vibration
goal of cleft repair surgery is to optimize: (5)
feeding
speech
dentition
aesthetics
facial profile
recommended timeline for cleft speech/language evaluation
0-3: counseling, feeding eval, hearing screening
3-4: full speech / resonance / VP eval
4-12: annual screening
12-18: every 2 years
components of a cleft & craniofacial assessment
history
orofacial exam
speech & resonance assessment
instrumental evaluation
stimulatbility / trial therapy
purpose of a speech & language screening for a child w/ a cleft
monitor development
ensure appropriate growth
guide parents in stimulating language
track milestones
why don’t we reevaluate speech/resonance until 3-5 years
the child must:
produce connected speech
cooperate w/ testing
have a large enough airway for surgery
what language development issues may arise in children w/ cleft palate
less consonant babbling
hearing loss (middle ear fluid)
late onset of words
atypical lexicon
causes of speech sound development issues in children w/ clefts
structural issues
neurologic issues
hearing loss
compensatory errors that become mislearned
what sensory areas important to monitor in children w/ craniofacial differences
hearing - common due to ET misfunction
vision - impacts speech learnin
psychosocial factors that might affect communication development
attention difficulties - often co-occur w/ language disorders
motivation - less pressure form families to communicate if speech is unintelligible
first step in speech/resonance assessment
perceptual assessment
what does a perceptual assessment determine
if a disorder exists
type & severity
likely cause
whether to treat or refer
tasks used to assess speech samples
single sounds & syllables - hypernasality & nasal emission
sentences - articulation & resonance
connected speech & conversation - real world impact
sounds & their purpose in single sound assessment tasks
vowels - hypernasality
/s/ - nasal emission
/m/ - hyponasality or cul-de-sac resonance
how do syllable repetition tasks help in assessment
oral voiced consonants & vowels - hypernasality
voiceless consonants - nasal emission
nasal consonants - hyponasality, cul-de-sac resonance
specific phonemes - sound specific errors
connected speech task to test hypernasality / nasal emission & hyponasality
hyper - counting 60-70
hypo - counting 90-99
how is conversational speech used in assessment
engage child in natural conversation / ask them to explain something
listen for resonance errors & intelligibility
what early evaluations are recommended for infants w clefts
feeding eval
language development monitoring
to ensure growth & development
how is early developmental progress monitored in children w clefts
parent reports
observation of speech milestones
what factors can limit language development in children w clefts
less consonant babbling
hearing loss
adult feedback issues
structural contraints
common causes of speech sound development issues in children w clefts
structural anomalies
neurological issues
hearing loss
what additional areas should be monitored in children w clefts
hearing
vision
attention
motivation
assessment timeline for children w clefts
0-3: counsel family, feeding/language eval
3-4: comprehensive speech/resonance eval
4-12: annual screening
12-18: every 2 years until dental/orthognathic treatment ends
goals of perceptual assessment
determine if disorder exists
type
severity
possible cause
treatment or referral
indirect instrumental procedures
acoustic or airflow measures
nasometry, aerodynamics
direct instrumental procedures
visualization
nasopharyngoscopy, videofluoroscopy
what does nasometry measure
nasalance score = nasal acoustic energy / total acoustic energy
what does speech aerodynamics assess
nasal airflow & pressure to estimate VP opening size or obstruction
why is team management essential in cleft/craniofacial care
treatments affect one another & require coordination across a long term multi-phase process
multidisciplinary team
independent work
little coordination
interdisciplinary team
collaborative care plan
transdisciplinary team
deep understanding across disciplines
who are the core ACPA members for a cleft team
surgeon
orthodontist
SLP
key roles of SLP in cleft ccare
counseling
feeding/swallowing
therapy
coordination w families & providers
speech / resonance
AuD role in cleft care
hearing screening
OAE / ABR testing
managing hearing loss
amplification
coordination w/ school services
standard of care for cleft conditions
inter/transdisciplinary team approach
main treatment categories for cleft care
surgery
speech/swallow therapy
dentistry
orthognathics
prosthetics
counseling
ultimate goal of cleft related speech therapy
normal speech & resonance
when is speech therapy effective vs not effective
effective for mislearning or phoneme-specific errors
not effective for obligatory errors due to structure (surgery needed)
what principles support successful speech therapy carryover
motor learning & memory
frequent short focused home practice
high reps per session
meaningful feedback
strategies for treating glottal stops
contrast glottal stops w correct sounds
use mirrors, tactile feedback, & coarticulation
how do you treat nasalized vowels or ng/l confusion
exaggerated yawning
stretch awareness
nasal occlusion
coarticulation for feedback
how do you treat phoneme specific nasal emission (PSNE)
start w loud /t/
close teeth
prolong shape into /s/
“tsssss”
