Managing Hypernasality Following Cleft Palate Repair

Question

I have a 4 year old hearing-impaired student with bilateral aural atresia and a repaired cleft palate. His cleft was repaired at 9 months of age and he has been receiving private and school-based speech therapy since 10/02 (so approximately 3 years). His

Answer

As we read this question, we can see that our lack of knowledge about this particular child is creating some uncertainty as to how we should respond regarding treatment recommendations for him. We can't imagine that a child with these kinds of profound problems hasn't been seen by a Cleft Palate Team, including a geneticist. Before providing recommendations for Tx, it is important that we better understand the clinical case. Perhaps we should get the following answers BEFORE we make any Rx:

1. Has the child been seen by a Cleft Palate Team? or, by an ENT only? Has a syndrome been identified? What does his repaired palate look like? Does he have enlarged tonsils? adenoids? Has nasal endoscopy been performed with consideration for analysis of possible VPI? How long has he had hearing aids? What kind? What does his aided audiogram look like? Does his SLP have experience with aural rehab? with cleft palate?
   
   
2. When did he last have a comprehensive speech and language assessment that includes: cognitive-linguistic, phonology, oral peripheral-neuromotor, and articulation batteries? Is he making progress on re-evaluation? Does the hypernasality vary with the articulatory context? What kind of preschool class is he in? Is he cooperative enough to undergo nasal endoscopy, or has it already been done?

With respect to assessment of articulation, the underlying articulatory problem should be identified by taking an inventory of speech error patterns (i.e., substitutions, distortions, deletions (in positions of words: initial versus final); error consistency or inconsistency, class type errors (i.e. anterior vs. posterior pressure consonants, high pressure consonants, phoneme-specific consonants such as sibilant fricatives and affricates). A simple mirror clouding test can also be performed during non-speech tasks, such as tense vowel prolongation (i.e. /i/) and connected speech tasks devoid or nasals (i.e. "we see three geese"). We also recommend applying a rating scale for subjectively rating nasal resonance during sentence repetition tasks and conversational speech.

Based on our initial impression, we suspect that the ENT evaluation would not be so much concerned with issues surrounding possible Otitis Media in a child with bilateral aural atresia, but on the possible profound conductive loss that the child may have all by itself. We suspect that he must have hearing aids if he has good language, so presumably he is already being followed by an audiologist. Cleft Palate Teams have an ENT, audiologist et al. on tap and are knowledgeable about these conditions, which is why we think the referral to a team is the first thing to do, if not done already.

Good references on the assessment and Rx of such cases include: Cleft Palate Speech by Peterson-Falzone, Hardin-Jones, Karnell; Sprintzen's book; and Bzoch's book, to name some.

Mary Andrianopoulos, Ph.D. UMass-Amherst
Associate Professor/Clinical Consultant

Dr. Mary Andrianopoulos is an associate professor at the University of Massachusetts-Amherst. Her research interests and clinical expertise are in the areas of sensorimotor speech disorders, voice analysis and quantitative acoustic-perceptual measurement, dialectal and vocal differences among culturally and linguistically diverse populations, differential diagnosis and rehabilitation of sensorimotor speech and voice disorders, neurological bases of communication disorders. She completed a two-year post-doctoral fellowship in medical speech pathology at the Mayo Clinic in Rochester, MN. In addition, she served as clinical consultant of otolaryngology at the Massachusetts Eye and Ear Infirmary and inpatient coordinator of Speech Pathology Services at Massachusetts General Hospital in Boston. She also served as an adjunct faculty to Harvard University's Medical Resident Training Programs in otolaryngology and neurology. She served as a Fulbright Scholar in Medical Sciences in the Department of Cognitive Sciences at the University of Athens in Greece during in 2003, where she currently serves as an adjunct visiting professor. Her research has been supported by private and federal organizations. The American Speech Language Hearing Association funded her research on vocal differences among culturally and linguistically diverse populations. She is the author of numerous journal publications, book chapters and training manuals. She has disseminated her research findings through more than 60 presentations and papers at national and international meetings. She is a reviewer for the: American Journal of Speech Language Pathology, Language Speech and Hearing in the Schools, and the New Investigators Program for the Voice Foundation. She is also the recipient of numerous outstanding teaching awards.

Daisy Mathias, M.S. Baystate Medical Center-Springfield, MA
Consultant, Shriner's Hospital Cleft Palate Team-Springfield, MA

Daisy Mathias received her Master of Science degree from McGill U. in Montreal in 1973, and has worked in the field of Speech-Language Pathology since then, specializing in pediatrics: at Children's Hospital Medical Center in Boston (where she was SLP on the Cleft Palate, Craniofacial and Outpatient Feeding Teams), at The Treatment Center in Rockville, MD, and at an early-intervention program in Westfield, MA. She has a certificate in NeuroDevelopmental Treatment. Ms. Mathias is currently on the staff at Baystate Medical Center, and is the SLP on the Cleft Palate Team at Shriners Hospital, in Springfield, MA, as well as pursuing private practice consultant work with the Western MA Early Intervention Consortium. She is a member of ASHA and of ACPA. Her husband, Bob Nelson, is a R.N., and they have one daughter who is a senior at the University of Chicago.