Question
What is the influence of middle ear management on articulation management with children who have mild to moderate VPI?
Answer
Early and aggressive management of middle ear disease and hearing loss in relation to cleft palate is critical for early speech-language development and long-term hearing and ear health. It is standard of practice to insert ventilation tubes at the time during infancy, usually in combination with the lip repair or palate repair if possible. Multiple sets of ventilation tubes may be needed, Children with submucous cleft palate are at similar risk because of how the anatomical difference impact Eustachian tube function. Children with VPI without a cleft palate may also be at risk, such as children with Velocardiofacial syndrome, who also have anatomical differences. Some of the secondary speech surgeries to manage VPI can also exacerbate Eustachian tube dysfunction, such as a pharyngeal flap as they can obstruct the opening. However, the benefit for this surgery usually outweighs this risk.
I do not know off the top of my head of published data showing a direct link between articulation skills and hearing loss or frequent otitis media in the cleft palate population or VPI but certainly I can speculate that children with poor hearing will have increased use of compensatory articulation errors. I do not know of a direct link between severity of middle ear dysfunction and the severity of VPI. In regards to managing middle ear disease and hearing, there is published data from a the University of Minnesota from Moller and colleagues that followed children from 9 to 30 months with cleft palate with matched peers without cleft palate. This study found significant differences on language and cognitive skills between the groups. Cognitive differences were linguistically based and furthermore the group differences were not significant when hearing and velopharyngeal function were added as co-variates. This builds the case for early and aggress management of middle ear disease and hearing and providing adequate velopharyngeal closure at a young age.
Perhaps more directly related to your question, is whether or not hearing loss and middle ear dysfunction places children with cleft palate at risk for increased use of compensatory articulation errors, such as glottal stops, pharyngeal fricatives, phoneme specific nasal air emission (e.g., posterior nasal fricative substitutions). At the 2011 American Cleft Palate Meeting in Puerto Rico, there were several presenters who provided clinical data and experience supporting that children with long history of otitis media have increased frequency of phoneme specific nasal air emission. Dr. David Zajac, SLP from the University of North Carolina has published and presented research and I believe continues to research hearing and the acoustics of speech in the cleft and craniofacial population and has done some great work in the area of nasalance.
The take home message is that it is critical that every child with a cleft palate or VPI should be seen by a cleft team, which always includes an audiologist, ENT and speech-language pathologist and many more specialists. Velopharyngeal inadequacy and hearing should be managed aggressively. Teaching correct sound placement skills requires stable hearing thresholds!
Anna Thurmes is the Program Coordinator and supervising speech-language pathologist at the University of Minnesota Cleft Palate-Craniofacial Program with expertise in velopharyngeal dysfunction, articulation, and feeding in an interdisciplinary team care setting. Anna serves on the Board of Directors for the Cleft Palate Foundation, as well as the Americleft Task Force Committee.
