Final Flashcards
Single Word intelligibility test
% words correct (by listener) is severity indicator/explanatory power (w/ phonetic contrast analysis); reliability: Zajac 6-12 words/50 word set; Computer Mediated Speech Assessment System: + reliability (.92-.95) found CL/P group 67% intelligible (peer 85%)
Phonetic contrast findings for intelligibility CLP
78% (control 93%); their error: alveolar (velar stops, palatal fricatives), fricative (affricative), liquid (glide w)
Causes of VPI
Cleft palate/SMCP (20% post surgery); congenital short palate/deep pharynx; mechanical obstruction (tonsils, adenoids, posterior pillar web); Ablative palatal lesions (cancer, trauma); Neuromotor (dysarthria); Motor Planning (Apraxia); Sensorineural hearing loss; maxillary advancement
VPI terms (VPI, insufficiency, incompetency)
inability to separate oral and nasal cavities during speech; lack of tissue; neuromuscular)
Obligatory Speech Characteristics
active; usually w/ LARGE VP gap; nasalized plosives, hyper nasal, reduced loudness, nasal air emission (especially voiceless stops), weak oral pressure (Po reduced)
Compensatory speech characteristics
learning; compensate for VPI/other structural anomaly; PLACE changed to preserve MANNER of artic; pharyngeal fricative and glottal stop (comp for VPI valve), mid dorsum palatal stop (comp for palatal anomaly such as ONF, teeth, arch); 25-30% children w/ CLP, more prevalent in bilateral CLP
Speech characteristics of VPI
hypernasalisty, audible nasal air emission (esp voiceless consonants), weak pressure consonants, compensatory articulators
Cul-de-sac resonance
pharyngeal cavity; due to obstruction (e.g., large tonsils, small jaw & glossoptosis, VPI & anterior nasal blockage)
Hypernasality
excessive nasal resonance that affects VOWELS and VOICED consonants
Nasal cavity air mass can resonate due to
direct coupling via VP gap; sympathetic coupling via structures (e.g., vibrating velum)
Denasality
total nasal airway obstruction
Hyponasality
reduced nasal resonance on NASAL CONSONANTS and VOWELS; obstruction in nasal cavity/nasopharynx; “head cold” sound
Mixed resonance
hyper & hypo w/in same utterance; often w/ pharyngeal flaps
Vowel type & perceived nasality
low vowels more nasal than high vowels for non-cleft; high vowels (ee, i, oo, uh) more nasal than low vowels (a, aye) for cleft (High vowels have greater velar height)
Hypernasal perceptual judgment scales: Equal Appearing Interval (EAI)
equal interval squares
Hypernasal perceptual judgment scales: Direct Magnitude Estimation (DME)
Judment relative to “modulus” w/ has assigned (arbitrary) value; ratio judgment relative to modulus
Prothetic stimuli
changes in QUANTITY or MAGNITUDE; eg, loudness; DME scales better (If DME and EAI scales are NON-LINEAR, stimulus is prothetic)
Metathetic
stimuli changes in QUALITY; SUBSTITUTIVE can use EAI or DME
Hyper nasality may be ______ in nature, so _____ scale is best
Prothetic; DME
Nasal Air Emission determined by
Respiratory effort (Po); size VP gap; potency of nasal cavity (snot)
Nasal Air Emission detection
visible (mirror–> VP gap, ONF); audible (forced exhalation on plosives); turbulent (nasal rustle due to small VP gap plosives/sibilants)
Kummer theory: Nasal Air Emission
Nasal rustle (turbulence) caused by airflow through small VP gap resulting in bubbling of secretions
Zajac theory: Nasal Air Emission
velar flutter caused by vibration of velar/pharyngeal tissue accompanied by turbulent airflow (maybe secretions too)
Types of compensatory misarticulations
MANNER maintained, PLACE is POSTERIOR; glottal stop for /b/, pharyngeal stop for /k, g/, pharyngeal fricative for sibilant, affricates (e.g. /s/), mid-dorsum palatal stop for /t, k/; velar fricative for sibilant fricatives (s, z, sh, zh); posterior nasal (VP) fricative w/ audible NAE; nasal fricative- nasal snort, voiceless nasal consonant for oral stop
Cause of compensatory misarticulations
early phonetic development before surgery, tx: surgery before onset of meaningful speech
Dental/alveolar anomalies cause of mid-dorsum stops b/c
CPO kids show only glottal stops; CLP kids glottal stops, mid-dorsum, pharyngeal fricative & stops
Other unusual articulations in children w/ CLP
clicks, sibilants on inhalation, nasal grimace
Articulation error patterns in CP
omissions & substitutions most frequent; fricative/affricate (s most common) > plosives . gildes; frequent /l, r/ errors (maxillary/palatal anomalies; voiceless > voiced (higher pressure, VPI leads to voicing)
CP changes vowel production
extra nasal formant below F1, extra formants above F1, increased frequency F1; Reduced amplitude and frequency of F2; increased formant bandwidths
Tonge position changes in CLP
HIGH and RETRACTED; increases oral impedance & nasality; reduce frequency of F1 & F2
Speaking rate & CP
adults read slower; decreased word production time REDUCED nasality (faster rate for hearing impaired individuals also decreased nasality rating, narrowed F2 bandwidths, less VP contact @ slow rate, decreased compliance of vocal tract walls –> narrower bandwidths
Developmental factors on nasality in young children w/ CLP
INCREASED nasality due to longer vowel duration, and INCREASED ANE due to longer consonant durations, higher oral pressure, smaller nasopharyngeal cavity; possible REDUCTION in symptoms w/ age
Voice disorders in CP
high prevalence- perceptual, vocal fold nodules; “Soft Voice Syndrome” to disguise nasality?; laryngeal hyper functioning due to strategy to increase effort/close VP, ST?;
Stuttering in CP
low prevalence; delay linguistic maturity, accepting parents, aerodynamic of vocal tract???
Clinical Assessment of VPI
GLOBAL judgment of resonance (hyo/hyper), Audible nasal emission, Arctic (intelligibility? developmental/dental errors, compensatory misartic), vocal quality & prosody from spontaneous speech sample (or elicited: counting, CV syllables, sentences) ; can manipulate rate or LOUDNESS; ask: child usually like this?
Nasal Emission Testing (regular (school) clinic)
mirror (con- poor time measurement); test nasal breating, CV syllable, sentences, gauge consitent? reduced/absent nasals? *Test /ki/ is anterior ONF
Nasal Emission Testing: SeeScape
Pro: good for feedback or oral airflow; Con: may encourage nasal emission
Do mirror testing _______ perceptual testing for Audible Nasal Emissions (time)
AFTER (sometimes emissions but not perceptual, don’t bias)
Clinical assessment during elicited speech samples
isolated vowels: high vowels- open vs pinched nostrils (change?- if goes to cul-de-sac, VPI; no change- adequate VP closure)
Oral Peripheral Exam for CP
Check hard palate/alveolar ridge for: ONFs, cleft, height of palatal vault, scarring; check soft palate for: length, symmetry on phonation, SMCP, LPW movement; tonsils (size, obstructing?)/adenoids; Dental occlusion/corssbites/missing or extra teeth; Tongue lips & mandible- size/sphage, ROM, strength; CN function test
Articulation testing for CP
Audio record, use standardized test, transcribed w/ diacritics; Intelligibility- global (mild, mod, severe), % from conversation, % single word (Unbiased, objective outcome measure); arctic errors may be: developmental, due to dentition, dyspraxia/dysarthria, due to VPI (obligatory, compensatory)
Assessment: Nasal Emission
visible, audible? (Audible NE vs nasal turbulence, or combo); consistent? or phoneme specific
VP function assessment
WNL: NO visible nasal emission, normal resonance; ADEQUATE: mild nasality, Visiblie, sometimes audible nasal emissions; MARGINAL: consistent Aud/Visible NE; mild-mod nasality; reduces loudness/vocal dysfunction/some compensatory errors possible; INADEQUATE: consistent visible and aud NE; mod-severe nasality; reduced Po & loudness/vocal dysfunction/compensatory and nasal substitutions likely
VP Inadequacy recommendations
instrumental assessment; surgical management; prosthetic management
VP Marginal recommendations
stimuable? resonance- rate, loudness, mouth opening manipulation; NE- contact pressure “quick & light” manipulation, feedback; Artic- stumble for anterior placements if based?
ST appropriate for children with marginal VP function IF
stimuable l for resonance/NE (CPAP?); stimuable for arctic - tx for placement (could reduce nasality, improve VP function)
How to determine status of stimuli on perceptual rating scales
linear=metathetic; curved=prothetic
Obligatory (passive) nasal emission
generated @ anterior nasal valve- hissing/turbulent sound w/ stops & fricatives, large VP gap; generated @ VP valve- raspberry/periodic sound, small VP gap
Active nasal fricatives
generated @ anterior nasal valve- hissing/turbulent sound REPLACES stops & fricatives, oral cavity occluded, large VP gap; generated @ posterior VP valve- raspberry/periodic sound, oral cavity occluded, small VP gap
Acoustic nasometry
OBJECTIVE measure of resonance called nasalance, moderately correlated w/ perceived resonance; Fletcher, 1970
Nasometer equipment
headset w/ nasal & oral mics, sound separator place; acoustic processor- bandpass filter, A/D converter, software
Acoustic nasometry
gives % NASALANCE= nasal dB/(total (oral + nasal) dB) x 100 (eg, 100% nasalance for /m/, 0% for eeee); in practice, acoustic CROSSOVER occurs
Nasometer filtering
bandwidth; 350 to 650 Hz to capture nasal formant, centered at 500Hz; poor slope of filter (24dB/octave);
Nasalance norms
zoo passage: 15%, rainbow (11% nasal): 35%; nasal sentences: 61%; vary by geographical dialect
Nasalance scores for speakers with VPI
28% Zoo passage cutoff score;
Nasometer considerations (“caveats”)
mics: sensitivity & frequency must be closely MATCHED; careful across machines; Nasal air emissions during VOICELESS sounds may inflate nasalance (so use “low pressure” voiced stimuli); vowel effects by tongue height NOT VP opening;may be affected by bandpass filter, NOT VP opening, higher nasalance for females; acoustic crossover between mis- sympathetic VIBRATION of closed soft palate(transpalatal nasalance); maybe affected by pitch- increased on /a/ INCREASED for men
Transpalatal nasalance
sympathetic VIBRATION of closed soft palate; implies some degree nasality may occur even w/ normal VP closure; pitch may be a factor; maybe some surgeries optimize acoustic impedance to sound better? Furrow lengthens, thickens velum
Nasometry pros & cons
objective, non-invasive, good for kids, normative data, feedback potential; inflation due to nasal flutter (> true nasalance), comparison across centers problematic, NOT true index of VP opening but relative oral-nasal resonance balance
Benefit of assessing aerodynamics
COMPREHENSIVE evaluation much include instrumental techniques to prevent bias
Advantages & disadvantages of pressure-flow as instrumental technique
Non invasive, kinda cheap ($$$ endoscopy, $$ pressure flow, $ nasometry), provides OBJECTIVE info, children young as 3-6, no physician oversight needed; kinda expensive, complicated techniques (calibration of flowmeter, pressure transducers, orifice area equation); few “commercial” vendors
Aerodynamics and VPI speech characteristics
50% VPI speech characteristics aerodynamic by definition (nasal air emission, reduced oral air pressure); hypo nasality and compensatory arctic also may have aerodynamic components
Velopharyngeal port essentially functions as _____
an AEROMECHANICAL VALVE to separate oral & nasal cavities during speech; PRIMARY goal of palatal surgeries=restore structural and aeromechanics VP integrity, so aerodynamics should be PRIMARY procedure to assess surgical conditions
Low-tech aerodynamics assessment tools
Mirror, See-Scape (shouldn’t rise), listening tube
Low-tech aerodynamics assessment caveats
INADEQUATE temporal resolution; affected by speaking rate; could be due to velar bounce; nasal-plosive phonetic contexts; patients could misinterpret;
Pressure-flow technique
method to calculate MINIMUM cross-sectional area of VP orifice; hydrokinetics; Need 3 things: vocal tract pressure measurements (Oral and nasal pressure, differential pressure), nasal airflow measurements (Vn), and VP area calculation
Warren (19640 modified pressure-flow to allow____
DIRECT determination of differential oral-nasal pressure across VP port, but limited to bilabial consonants
Pressure-flow: Accuracy of VP area estimates
depends upon value of K; if rounded inlet geometry of orifice, k=.97; by using .65, may overestimate VP area up to 30%, but unknown for every speaker/norms .65; VP area estimates are RELATIVE
Pressure-flow: Instrumentation
2 air pressure transducers: positive and negative pressures, heated prneumatachometer (flow meter), A/D converter, signal processing software, calibration equipment
Standard pressure-flow technique
requires potency of both nostrils; Po detected behind lops, Pn detected by occulting one nostril (stagnation pressure continuous w/ downstream VP port; eliminates nasal cavity resistance); nasal airflow detected by flow tube
Pressure-flow measurement of oral cavity
can be easy OR hard to obtain; catheter must be BEHIND structure of interest; EASY for bilabial, ~easy for ALVEOLAR, DIFFICULT for velar; orientation catheter NOT critical for stops
Pressure-flow measurement of nasal cavity
catheter must be DOWNSTREAM of VP orifice; insert into nostril via cork, foam plus, nasal olive; Requires flow meter, nasal flow be, flow from most patent nostril
VP orifice area for /pi/
Adequate VP function: 0mm squared, marginal VP function: 12.72,
Normal VP closure for Stop consonants
Po 3-8 cm H20; greater in children than adults; NO nasal airflow but beware of onset/offset flow, velar bounce, tonsillectomy/adenoidectomy
VP function by phonetic context of /p/ CV VP area
NORMAL/complete closure: VP area =,,= 10.0
VP function by perceptual symptoms
ADEQUATE: generates usable Po, but inconsistent nasal rustle, mild nasality possible; MARGINAL may have reduced Po, audible NE, mild/mod nasality, INADEQUATE: reduced Po, audible NE, mod/severe nasality
VP port timing
may be as important as size of opening; high correlation between VP closing DURATION in nasal-plosive sequences & perceived nasality
VP closing duration
Duration of nasal flow decline in “hamper” from the PEAK NASAL AIRFLOW to 5% baseline airflow; 50-80 ms
Considerations using VP Closing Time
need STANDARDIZED norms; need to NORMALIZE VP closing time to word duration to control for speaking rate
Differential pressure determination for young children
NO nasal flow tube (no area calculation; give visual feedback to make a game w/ oral catheter and nasal plug
Differential pressure /m/ VP function
> 3.0, ADEQUATE; 1.0-2.9 MARGINAL;
Nasal Mask Approach for pressure-flow measurement for young children
nasal mask (airflow AND downstream pressure) w/ oral catheter for upstream pressure; avoids nasal plug, good for bilateral cleft, unilateral nasal obstruction, fear of nasal plug; Permits calculation of VP area; requires differential pressure CORRECTION (must SUBTRACT nasal pressure drop to obtain (larger) true VP area)
Nasal Mask ONLY Approach for pressure-flow measurement for young children
obtains AIRFLOW, NO oral catheter, mic for audio; useful for child w/ lip incompetency, fear of oral catheter
VP function /p/ CV by nasal flow
ADEQEATE nasal flow ,20-30 mL/s (includes velar bounce); MARGINAL 30-150 (influenced by respiratory effort/nasal resistance); INADEQUATE >150ML/s
Objective assessment of VP port
methods: videofluroscopy, nasoendoscopy, pressure flow techniques; Pro: obejctive, reliable assessment of VP mechanism; CONS: expensive, invasive, dean child’s cooperation (better if child 4+)
Importance of early VP mechanism assessment
feedback for surgeons & STs: 20-30% children w/ CP may need secondary palatal children, 60-70% need ST
Nasal Ram pressure
VP status of stop consonants coded relative to NRP: Open VP- POSITIVE NRP; closed VP- ATMOSPHERIC NRP
Pros & Cons of the Pressure-Flow Method
non-invasive, objective, good norms, lots info: Po, Pn, Vn, VP area estimate; Technical (calibration, easy to make errors), RELATIVE > actual VP area, may not highly correlate w/ perceived hypernasality
Endoscopy
Optical instrument; requires high-intensity light source
Nasoendoscopy
use of endoscopy to evaluate VP function during speech; scope passes through nose, but DIRECT view of ENTIRE VP port difficult; nasal aspect velum/posterior pharyngeal wall seen
Nasoendoscopy considerations for the SLP
invasive procedure; increased legal risk; remain w/in scope; requires oversight of physician
Points of resistance when passing nasal scope
vestibule/opening; internal nasal valve (smallest cross-sectional area), chin; use universal precautions
Nasal Cycle
alternating congestion/decongestion of 2 nasal passages; sympathetic/parasympathetic CNS control; total resistance remains constant; most active in teens/young adults; decreases w/ age; 40 min-several hours
Nasoendoscopic procedure
Patient prep (before day of), END for decongestant, topical anesthetic,
Nasoendoscope CONTRAINDICATIONS
developmental delay, confusion, combative behavior; laryngospasm history; reaction to local anesthetic; bleeding disorder; refusal
Televex (multi-view video fluoroscopy)
direct imaging technique; provides MULTIPLE views of VP closure; barium contrast
Base view VP closure patterns
circular gap (= from velum AND lateral pharyngeal walls); Coronal (Bell Bar) Gap- primary contribution from velum; Saggital gap- primary contribution from Lateral Pharyngeal Walls
Televex procedure
lateral view: speech w/ NO barium, then barium sips for ONF and nasopharyngeal reflux assessment; then lay on back, barium in nostrils- sniff & swallow; base view: pt on stomach w/ head upright- assess VP closure during SWALLOW and SPEECH (LPW movement); Frontal view (pt stands)- LPW motion during SWALLOW & speech; Lateral view again- full barium coating of nasal and oral- assess VP closure during SWALLOW, velar elevation and pas savant’s pad during speech, lingual postures
Videofluoroscopy pros & cons
real images, less invasive than endoscopy, surgical planning relative to eight of flaps @ level palatal closure; real image, difficult to quantify, radiation exposure
Lateral Cephalogram disadvantages
radiation, limited to single sound, vowels not always closed in non-cleft speakers (30% misdiagnosis from MVVF)
_____ obligatory symptoms (3) require ________
SIGNIFICANT (hyper nasality, AUIBLE nasal emission, weak pressure consonants); PHYSICAL management (prosthetics, surgery)
Speech tx for compensatory misarticulations appropriate if
errors RETAINED in presence of adequate structure; goal to teach placement PRIOR to planned diagnostic/physical management; no hx ST and errors inconsistent (e.g., oral stops produced in come contexts)
Secondary palatal surgeries- posterior pharyngeal flap
mod/large CENTRAL CIRCULAR VP gap due to poor velar movement or short velum; need LPW movement; adverse side effects;
Secondary palatal surgeries– Sphincter pharyngoplasty
small LATERAL VP gaps, need velar movement, fewer side effects
Secondary palatal surgeries- - Furlow double-oppsing Z-plasty
lengthens palate; may increase velum thickness (for less acoustic transfer of sound energy)
Secondary palatal surgeries- posterior pharyngeal wall augmentation -
implants; rolled flap; division of pharyngeal flap becomes a “rolled flap”
Physical managements: Palatal lift
removable; ELEVATES and HOLDS velum agains posterior pharyngeal wall; useful for NORMAL velar length (poor movement- neurogenic disorders); contraindicated if severe gag reflect, poor oral hygiene, missing teeth
Physical management: Speech bulb obturator
removable; OCCLUDES VP gap; useful for short velum (VP insufficiency), interacts w/ VP muscles to dynamically, functionally control or-naso airflow; therapy: gradually DECREASE size of bulb every 3-4 months w/ goal: stimulate normal velar or LPW movement
Indications for prostheses w/ surgery
pharyngeal flap failure w/ redivision; temporary obturation may indicate potential effectiveness of surgery
Speech tx goals
change VP muscles (strength, endurance, mass); Change VP activity (coordination, rate, consistency); Reduce speech s/sx by changing respiratory effort, phonation, artic
Why milk shake therapy sucks
assumes VP weakness is cause for hypernasality; uses tongue to palate contact instead of velum to posterior wall contact in speech; assumes vp closure for sucking w/ carryover to speech
Non-speech oromotor tasks evidence
VP closure during speech is precise, automatic- during blowing, gross, purposeful; VP patterns different than speech; *but may be helpful for SWALLOWING
Continuous Positive Airway Pressure
CPAP; “exercises” velum w/ disyllabit stimuli; second oral/sibilant syllable is STRESSED; gradual increase in exercise time and nasal pressure resistance;
CPAP pros & cons
based on exercise principles sci, incorporates speech production; expensive, technical, limited data, effects could be due to increases respiratory effort, oral resonance, or improved VP timing, promotes idea that palate is weak, increased nasal resistance ONLY occurs during vowels wen mouth is open
Home Resonance Program (HRP)
CPAP w/out CPAP (use disyllabic model, “strong voice: for 2nd (oral) stressed syllable); use w/ ADEQUATE to MARGINAL VP function, SOFY VOICE SYNDROME; based on idea that hypernasal due to poor VP closure timing (long/slow), or limited effort; stress in nasal-obstruent sequence to improve timing
HRP Pros and Cons
based on sci, uses speech production, inexpensive; limited data, maybe limited to “sot voice syndrome”
PiNCH Prolonged Nasal Cul-de-Sac w/ High Pressure Speech Acts
targets hypernasality; patient occludes nostrils for 40+ min, reads/repeats series of words w/ high pressure oral phonemes and vowels (some improvement in n=4)
4 “physiological principles” of VP function in PiNCH
Nose occlusion will increase Oral Pressure, VP closure (mixed data); tx should include speech; speech should NOT include retracted sounds b/d they don’t need VP participation (pharyngeal, glottal); Increase in subglottic pressure will facilitate VP closure– use voiced sounds
Early intervention w/ CLP
Parent training ESSENTIAL; technique to stimulate language/INCREASE vocalizations (add sounds not currently used), “joint listening” for oral (> glottal) productions; provide word lists w/ /h, m, n, w/ consonants, occluding nares for oral sounds; post surgery- bilabial stop, voiced stop word lists; POSITIVE REINFORCEMENT to prevent glottal stops
Speech tx BEFORE palate repair; BEFORE pharyngeal flap surgery
may focus on vocalic & nasal sounds- encourage speech in early years, NOT due to weak muscles; teach correct oral placements/eliminate glottal stop (may improve VP function/inform surgical recommendations)
Speech tx after surgery
w/in 1-2 weeks; expand phonetic inventory by modeling lip/tongue/cheek movement in mirror, model specific CV syllable targets
Materials needed for CLP tx
mirror, nose clip, other regular stuff
EI w/ focused stimulation
to improve parent interactions & child’s vocab/artic; based on needs of toddlers w/ CP: limited vocal, restricted sound inventory, compensatory misartic, potentially reinforced glottal stops; parent training (model, respond w/ expansion) ; increases CLP toddler MLU, # total words, # different words #, decreased % glottal stop
Preschool/School Age speech tx for children w/ CLP
NEED informed parents/home component; individual sessions > in class (compensatory errors unique); 6-12 months, 20-30 min, 3-5x/week
Preschool CLP ST
EXPAND consonant inventory by teaching placement, teach spelling for target sounds, teach contrasts (min pairs)
School SLPs and Alveolar bone grafting (g/k)
age 8; reassess kid after surgery, short-term tx is stimulable for sibilant distortion, discontinue during maxillary expansion IF rapid
Jaw (orthognathic) surgery
adress dentition related errors, assess VP function
Eliminating compensatory errors (g, k)
child must UNDERSTAND problem; start w/ h to eliminate glottal stop, promote oral airflow, use to shape future sounds; nonsense then real words, CV to CVC, maximize (100/session) CORRECT productions; use placement map, aud discrimination, whisper for ABduction and more oral flow, add voicing to end/decrease /h/ “PhAY”
Feedback as SLP
direct, specific w/ instructions and feedback; negative practice AFTER child has established target
Tx for pharyngeal/posterior nasal fricatives
planet map; occlude nose; prolong /t/, then eliminate t, straw for central tongue groove/feedback
Tx for palatal/pharyngeal fricatives
overcorrect- teach interdental /th/, gradually extinguish
Appropriate needs & contraindications for ST (Kummer)
hypernasality/nasal air emission due to apraxia or dysarthria; compensatory artic post surgery; compensatory artic secondary to VPI, learned PSNE; NOT if cause structural (VPI/malocclusion) unless won’t be corrected
Speech tx: hypernasality
auditory discrimination, learning voluntary control, increased effort/oral opening, lower tongue dorm (practice w/ yawn), biofeedback (listening tube, nanometer visual, nasal vibrations tactile)
Speech tx: Nasal air emission
auditory discrimination, cul-de-sac (occlude nares), light quick contacts, biofeedback (listening tube, air paddle/nasometer, tactile from nose or mouth burst release)
Speech tx overall (Zajac thoughts)
Listen to and teach parents; explain surgery outcomes/limitations and avoid for velar movement problems; ST first for INCONSISTENT VP closure; change speech one syllable @ time; gross perceptual symptoms may diminish w/ age/growth
Phoneme specific nasal emission
mostly in sibilants/affricates; could be others (f, v, tr); Variable contextual expression; produced as POSTERIOR NASAL FRICATIVE, coarticulated oral stop (mid-dorsum to palate or alveolar ridge (t, d), velum (k, g), bilabial (p, b); VP port OPEN but reduced in size, causing velum vibration to resonate nasal airway; non-stop oral phonemes NORMAL VP closure; w/ or w/out PVERT structural anomalies
Active Nasal Fricatives
59% showed oral closure, nasal friction during /s/
Children w/ repaired CP and PSNE
ARE candidates for ST; nostril occlusion w/ sustained s, nasometry visual and negative practice, then self-monitoring
