SpeechPathology.com Speech Pathology logo Phone: 800-242-5183
Therapy Source Career Center

Treatment of Hypernasality in Children with Down Syndrome

Treatment of Hypernasality in Children with Down Syndrome
Bridget Russell, Department of Speech Pathology
May 1, 2006
Share:

Abstract:

Adenoidectomy has been reported to be a causal factor of velopharyngeal insufficiency (VPI) and associated hypernasal speech in patients with and without palatal and oral-pharyngeal defects. Children with Down Syndrome (DS) often have tonsillectomy and/or adenoidectomy to treat otologic, upper airway and sinonasal disease. Secondary to their altered head and neck structures, there is an increased possibility for VPI. Treating hypernasality may require surgical intervention including sphincter pharyngoplasty or pharyngeal flap, prosthetic devices or behavioral speech therapy to improve velar contact with posterior and lateral pharyngeal walls. Specific speech treatment regimens may include direct articulation-phonological therapy, biofeedback and muscle training. Combined surgical intervention and speech therapy may also be implemented. The following discussion addresses previous and current surgical, physical and behavioral treatment regimens to improve hypernasality in patients with VPI.

Introduction:

Down Syndrome or chromosome 21-trisomy syndrome is a type of mental retardation, occurring in approximately 1 in 800 live births. Typical physical deficits in children with DS include abnormal head and neck structures which result in sinonasal disease, upper airway and otologic problems (Price, Orvida, Weaver & Farmer, 2004). Anatomical differences include macroglossia, hypoplastic nasal bones, a narrower, less voluminous nasopharynx and oropharynx and eustachian tubes which have a less acute angle to the hard palate and a smaller diameter (Brown, Lewis, Parker, and Maw, 1989).

VPI is described by any of the following: velopharyngeal inadequacy, velopharyngeal insufficiency, velopharyngeal incompetence, or velopharyngeal dysfunction. These terms are used interchangeably to denote any type of velopharyngeal closure problem. This article uses the term velopharyngeal insufficiency or rhinolalia aperta to describe the failure of apposition of the soft palate and orophayngeal wall during speech, which is the main cause of hypernasality. In hypernasality, air escapes into the nose causing difficulty with speech, especially high pressure consonants such as plosives and fricatives. However, in the clinical management of these disorders, various etiologies require different management approaches.

As a result of anatomical differences, children with DS often present with symptoms such as; snoring, sleep apnea, nasal drainage, nasal congestion, mouth breathing, acute and chronic otitis media, drooling and tongue protrusion. Due to upper respiratory and structural differences, children with DS often undergo surgical procedures to help alleviate these symptoms. One procedure regularly performed is tonsillectomy with/without adenoidectomy ("T&A"). These procedures are often recommended to correct sleep apnea and other obstructive symptoms, despite controversy regarding their effectiveness (Price, et.al., 2004). Often, these surgical treatments do not account for the possible complications or side effects that may occur secondary to changing the anatomical structures in these patients. DS children have smaller-than-normal adenoidal pads and adenoidectomy may not have the expected positive result on nasal respiration and otologic problems as was previously thought (Kanamori, Witter, Brown, Williams-Smith, 2000). Furthermore, it has been noted that reducing the already small adenoidal pad in DS children may cause associated velopharyngeal insufficiency and therefore possibly creating hypernasal speech (Kavanagh, Kahane & Kordan, 1986).

Estimates of the incidence of velopharyngeal insufficiency after an adenoidectomy in non-syndromic patients has been estimated between 1 in 1500, to 1 in 10,000 procedures (Parton, & Jones, 1998). Other studies indicated that DS children post-T&A have benefited from the procedure by eliminating or reducing symptoms such as snoring, sleep apnea, nasal drainage, and mouth breathing, but not drooling or tongue protrusion. This data was reported via a parental questionnaire survey of 74 parents of children with DS (Price et al., 2004). The same report indicated two children had hypernasality after surgery. The children were given complete speech and language evaluations and additional assessment using cinefluoroscopy. Structural and functional causes of hypernasality were identified. Structural abnormalities included a high-arched short hard palate and a short soft palate. Contributing functional factors included hypotonia, slowed motor learning and oral motor developmental delay. The incidence of postoperative hypernasality found in these patients was higher than in the general population and therefore is essential to consider prior to the performance of an adenoidectomy in DS children (Kavanagh, 1986). The likelihood of post-surgical complications and possible secondary surgical procedures included chronic ear drainage and subsequent ear surgery, post-extubation stridor and respiratory problems. Whichever decision is made regarding adenoidectomy, the surgeon and family should be well informed of these recent findings to appropriately weigh the potential benefits and risks.

This page The rest of this article is not available, because you are not logged in to your SpeechPathology.com account.

Join Now to get the whole article and handouts.
This page The rest of this article is not available, because you are not logged in to your SpeechPathology.com account.

Join Now to get the whole article and handouts.
This page The rest of this article is not available, because you are not logged in to your SpeechPathology.com account.

Join Now to get the whole article and handouts.
This page The rest of this article is not available, because you are not logged in to your SpeechPathology.com account.

Join Now to get the whole article and handouts.
This page The rest of this article is not available, because you are not logged in to your SpeechPathology.com account.

Join Now to get the whole article and handouts.
This page The rest of this article is not available, because you are not logged in to your SpeechPathology.com account.

Join Now to get the whole article and handouts.
This page The rest of this article is not available, because you are not logged in to your SpeechPathology.com account.

Join Now to get the whole article and handouts.
This page The rest of this article is not available, because you are not logged in to your SpeechPathology.com account.

Join Now to get the whole article and handouts.
This page The rest of this article is not available, because you are not logged in to your SpeechPathology.com account.

Join Now to get the whole article and handouts.

bridget russell

Bridget Russell


Department of Speech Pathology



Related Courses

Assessment of Speech Sound Disorders in Children with Cleft Palate &/or VPD
Presented by Angela Dixon, MA, CCC-SLP
Video
Course: #6723 1 Hour
This is the 1st course in a 4-part series, SSD in Children with Cleft Palate and/or VPD. This course will review the primary components involved in assessing speech sound disorders in children with cleft palate and/or velopharyngeal dysfunction (VPD). Functional tools/techniques will be highlighted with the goal of determining when speech therapy is beneficial and when further medical referrals are necessary. (Part 2: Course 6718, Part 3: Course 6734, Part 4: Course 6733)

Birth to Three - Special Considerations for Speech Sound Disorders in Children with Cleft Palate &/or Velopharyngeal Dysfunction
Presented by Anne Bedwinek, PhD, CCC-SLP
Video
Course: #6718 1 Hour
This is the 2nd course in a 4-part series, SSD in Children with Cleft Palate and/or VPD. This course will focus on special considerations needed during the first three years of life for the child born with cleft lip-palate and/or velopharyngeal dysfunction. Emphasis will be placed on referral to and collaboration with a child’s cleft palate-craniofacial team. Principles and techniques will be illustrated for use during the first three years of life. (Part 1: Course 6723, Part 3: Course 6734, Part 4: Course 6733)

Therapy for the Child with Cleft Palate or Velopharyngeal Dysfunction
Presented by Lynn Marty Grames, MA, CCC-SLP
Video
Course: #6734 1 Hour
This is the 3rd course in a 4-part series, SSD in Children with Cleft Palate and/or VPD. This course will focus on speech therapy techniques for the child with articulation disorder related to cleft palate or velopharyngeal dysfunction. Practical therapy techniques that can be adapted for children aged 2 through the teen years are included. (Part 1: Course 6723, Part 2: Course 6718, Part 4: Course 6733)

Cleft Palate - What do I hear? What do I do?
Presented by Mary O'Gara, MA, CCC-SLP
Video
Course: #6733 1 Hour
This is the 4th course in a 4-part series, SSD in Children with Cleft Palate and/or VPD. Case studies will be presented to discuss assessment and therapy techniques for individuals with cleft and craniofacial conditions. Audiovisual recordings will be provided to demonstrate speech resonance, airflow control and articulation problems in this population. Therapy goal setting will be discussed, with specific techniques for compensatory articulation strategies. (Part 1: Course 6723, Part 2: Course 6718, Part 3: Course 6734)

Creating Family and Patient Friendly Materials, presented in partnership with Cincinnati Children's
Presented by Marlo Wahle, MS, CCC-SLP, Christine Lackey, MS, CCC-SLP, BCS-CL
Video
Course: #7661 1.5 Hour
This course will discuss the basics to creating family friendly materials. Presenters will demonstrate how to create educational handouts in the form of a newsletter and handouts that may be used within speech pathology sessions or as part of a home program.