CLEFT PALATE FINAL
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What are the 7 cosmetic goals of primary surgery on the primary palate?
- Vermillion Border into line
- Cupid's Bow preserved
- Mucous Membrane accurate union
- Nostril symmetry
- Lip fullness
- Tissue discard minimal
- Scar minimization/shrinkage
When is surgery for the primary surgery of primary palate timed?
- As early as few weeks to 3 months old
- Medically stable
What is the "Rule of 10s?"
- 10 weeks of age
- 10 lb weight
- 10 grams or higher hemoglobin count (RBC)
- 10,000 or less White Blood Cell count
What's the rationale for doing the primary surgery early?
- Trauma minimal for parents
- Feeding problems reduced
- Migration of premaxilla minimized
What's the rationale for doing primary surgery later?
- Tissue (more available)
- Acceptance of parents
- Concomitant problems present
What are 4 primary surgeries of the primary palate?
- Triangular Flap
- Rotation Advancement/Z-plasty
- Lip Adhesion
- Rose Thompson
- Straight Line procedure
What primary surgery of the primary palate is reserved for minimal clefts and is a straight line procedure?
The drawbacks of this surgery are that it sacrifices too much tissue (short lip) and that it destroys cupid's bow?
What primary surgery of the primary palate is reserved for more extensive clefts (prime)?
The advantages of this surgery are that it wastes little tissue, produces full lip, and has a natural cupid's bow.
The disadvantage of this surgery is that it creates an elongated lip on cleft side.
- Rotation Advancement
What primary surgery of the primary palate does the scar line up along the philtral ridge from the base of columella?
- Rotation Advancement
The advantages of this surgery are flexible lips and procedure, and easier revision.
- Rotation Advancement
What primary surgery of the primary palate creates 2 raw surfaces on each side of the cleft for better preliminary alignment prior to a later definitive lip repair?
What are the goals of the primary surgery of the secondary palate?
- Velar Mechanism that's functional
- Maxillo-facial growth (to avoid dish-face)
How is success measured for a functional velar mechanism?
What's the rationale for secondary palate surgery done early?
Functional Velum (so that at 18 mos. they can develop S-L)
What's the rationale for secondary palate surgery done later?
- Growth plates could be damaged
What are 7 subgoals of secondary palate surgery?
- Feeding easier
- Oral/nasal cavities separate for speech/swallowing
- Eustachian tube function improved (prevents OM)
- Upper Respiratory Infections reduced
- Growth of maxillo-facial complex improved
- Dentition functionality
- Palatal Vault normal
When is the primary surgery of the secondary palate timed?
Early as 9-12 months to 2 years old
What are the 2 most common primary surgeries of the secondary palate?
- Modified Von Langenbeck
- V-Y Retroposition/Veau-Wardill/W-Y
Which primary surgery of the secondary palate makes lateral incision along alveolar ridges, edges are pared, creates 2 bi-pedicled flaps,and tissue freed up so it can be slid toward midline and sutured to close cleft? It also leaves denuded bone where incisions made that will later fill with granulation tissue forming a scar that appears white.
Modified Von Langenbeck
The advantages of this surgery are that it emphasizes preservation of blood supply and growth retardation prevented by mucosa being sutured off?
The disadvantage of this surgery is limited length of velum.
Modified Von Langenbeck
Which primary surgery of the secondary palate is more common in the U.K. and prepares 2 uni-pedicled flaps leaving denuded bone?
The advantage to this surgery is that there's more potential for greater length of velum.
What's the primary veloplasty surgery?
Which surgery's goal is to recreate the levator sling by closing soft palate at early age and waits to repair hard palate until adolescence while pt wears a prosthetic device in hard palate to inhibit growth retardation of the maxillo-facial complex?
- Primary Veloplasty
What are 2 supplemental procedures to augment primary procedures in order to provide a better foundation?
Supplemental palatoplasty surgery that uses the mucoperiosteal tissue of the vomer to cover a unilateral or bilateral cleft palate. This procedure can be used to reconstruct the nasal or oral surfaces by either raising the vomer or creating a flap. Drawbridge closes the gap
Oral-Nasal Fistula can occur if this supplemental procedure is not done; soft tissue breaks down and hole results. Borrowing site usually from rip or hip.
What's the goal of secondary procedures of the secondary palate?
- Velopharyngeal Sufficiency achievement
- complements the primary procedure
What secondary procedure of the secondary palate creates a flap of muscle tissue bulge into the posterior pharyngeal wall in the hope that the bulge will become dynamic (like manmade Passavant's pad)?
What secondary procedure of the secondary palate implants some kind of inert/stable substance that won't do anything but will create a bulge that will hopefully make the distancein closing the gap. Silicon, teflon, collagen, and cartilage have been used for this.
What are the problems that can occur with pharyngeal implants?
- begins to slip into a wrong position (oyster) that's not beneficial
- Teflon is carcinogenic and can no longer be put in a human's body
What is the most common secondary procedure of the secondary palate?
What's the biggest drawback of the early versions of pharyngeal flaps?
- surgeon will now make flap bigger than needed
- child will be hyponasal for first 3 wks until swelling goes down
Most common pharyngeal flap where base is above the flap itself. If there's active muscle tissue it will elevate velum.
Superiorly based pharyngeal flap
Pharyngeal flap where base is below the flap itself. Does not aid in velar closure but will aid in lateral wall movement.
Inferiorly based pharyngeal flap
When will a pharyngeal flap surgery be done?
- By age 2 (early as 12 mos) to help with speech
- at age 2 a phonetic inventory on sounds can be done to check for nasality
- Sometimes they wait until 6-12 years old
- Palatal obturator
- Speech bulb
What's the best prosthesis for pts whom the soft palate is mobile but too short to adquately close the VP port completely? Provides surface for pharyngeal walls to squeeze against providing VP valving. May provide replacements for teeth.
Speech Bulb Palatal Obturator
Why are 4 reasons prosthetics may be used?
- Anesthesia contraindicated due to serious health cond.
- Insufficient tissue to reconstruct palate surgically
- Supplement unsuccessful primary surgery
- During waiting period prior to surgery
What type of prosthetic is used when velum is intact but has inadequate movement. This device lifts velum into a position so that when it moves it will come into contact with pharyngeal wall. Velum crutch.
What are the advantages of using cephalometerics?
- Radiation limited to one shot
- Process easy
- Widely available
What are the disadvantages of using cephalometrics?
- Static speech not dynamic
- Masking problem--may not pick up the gap due to summation of tissues
X-ray slices may detect what the masking of basic radiograph didn't but still requires static speech.
Computerized Axial Tomography (CAT scans)
What are the advantages of using videofluoroscopy?
- Dynamic connected speech=better VP function analysis
- Longer utterance
- High speed film
- Frame-by-frame analysis can be done
What are the disadvantages of using videofluoroscopy?
- Radiation exposure time (continuous)
- Limited to one view
- Not widely available
What's the name of the original oral parendoscope that was not useful because of rigidity pts couldn't talk, gag, and burnt from hot light bulb?
What are the advantages of using fiberoptic endoscopy?
- No radiation (light retrieves image)
- Dynamic speech
- Visualization of lateral wall/velar movements
- "Live"/recorded structure visualization
What are the disadvantages of using oral fiberoptic endoscopy?
- Speech interferement
- Gag reflex a problem for some
What's the disadvantage of using nasal fiberoptic endoscopy?
- Nasal obstruction
- deviated septum or overgrown turbinates
- Lateral wall movements not seen as easy
What instrument measures the amount of intraoral air pressure that can be exerted/generated by an individual and is no longer used?
What instrument uses a coil with an arrow attached sealed in a case to measure unit of intraoral air pressure by a person blowing through a tube, air compresses coil and the attached arrow moves to point to the numeric unit of air pressure? (An average of 3 measurements each w/ nares open/closed)
If person had a VPI, would they be most successful with nares open or closed when using oral manometer?
What's the advantages of using an oral manometer?
What are the disadvantages of using an oral manometer?
- Non-speech activity/blowing
- Reliability poor due to low effort/pain in Eustachian
What's the best instrumentation to detect VPI by translating fluctuations of air pressure into elecrical signals?
Pressure Flow Technique/Pressure Transducer
What instrument has one tube go in the mouth for oral pressure and two in the nose one with a nasal olive that measures nasal pressure during nasal sounds and another that is directed into a heated flowmeter that detects nasal emissions that cool a wire to increase electrical signal.
Pressure Transducer/Pressure Flow Technique
The pressure flow technique correlates measures of what?
- Nasal airflows vs.
- Oral & Nasal air pressure variations
If there's a big VPI leak, it'll take __________ to get nasal emission.
Less Oral Pressure
What are the advantages of using Pressure Flow Technique?
- Very small leaks can be detected
- Dynamic speech is used (contrasts low/high pressure)
What are the disadvantages of using Pressure Flow Technique?
- Location of leak cannot be determined
VPI rating of less than 5mm2
VPI rating of less than 5-10 mm2
VPI rating of 10-20 mm2
VPI rating of greater than 5-10 mm2
- Consistent VPI
- Surgery needed
This instrument measures resonance imbalance through acoustic energy by monitoring VP behavior during speech using microphones on a plate under nose, signals fed to computer creates a ratio of nasal acoustic energy divided by nasal acoustic energy plus oral acoustic energy.
Resonance which is the percent of all acoustic energy that is emanating through the nasal cavity.
What are the advantages of using a nasometer?
- Affordable ($3500)
- Dynamic speech
- Simple technology
What are the disadvantages of using a nasometer?
- VPI is only inferred
- No Nasal Emission information
What type of articulation errors are common in preschool?
What type of articulation errors are common in school-age?
- especially glottal stops
What type of articulation errors are common in adolescence/adults?
- nasal emissions
List the most to least difficult manner of production for speakers with cleft palate.
What's the most difficult place of articulation for speakers with cleft palate?
Front of mouth sounds
In what sounds is the glottis closed half the time so air pressure drops making them less difficult?
Regarding context, __________ are more difficult than single phonemes.
Better speech is associated with earlier surgery, what would be the main reason surgery was delayed?
Concomitant medical problems
What type of cleft will individuals most likely have better speech?
Primary cleft palate
If person that has cleft has nasal obstruction, why will their speech sound better?
- Path of least resistance-obstruction allows less air in nasal cavity
- Increases nasal impedance
Why does dentition/occlusion not affect speech much?
Tongue can adapt easily
Consistency is the _________ of specific consonant productions and the consistency of those productions.
What is the most typical specific articualtion error in cleft palate speakers?
- Nasal Emission due to hypernasality
- airflow/nasal turbulence/snort
- audible or inaudible
What test is used to evaluate phonetic context and tests consistency of phonemes production?
McDonald Deep Test of Articulation
Which instrumentation/procedure is best for measuring airflow (nasal emission)?
Pressure Flow Technique (nasal olives)
Nasal Emission almost obliterates /s/
Squiggly above /s/ with two dots
Nasal emission w/ Nasality
Double tildy above /s/
Snort or turbulent (twice as bad)
Tildy with line through it
Nasal emission ________ is the best/direct/physical evidence of a leak.
- distorts overall sound
- this isn't learned (either you have deficiency or you don't)
Compensatory substitution that is done to build up pressure right below port so won't have to rely on velum ("bottle"; "Lawton")
Glottal stop but moving the point of restriction up against posterior pharyngeal wall.
Compensatory strategy that presses tongue to back of pharynx; pressure is below velum (cough up hairball sound)
Compensatory substitution sounds like a "German /r/" or "Arabic" sound. (Curvy X)
Velar Fricative substitution
Compensation by valving with the nares; this is a learned behavior won't go away just because cleft is repaired.
What's the typical voice quality of cleft palate speakers?
Often cleft palate speakers exhibit ________ pitch in their voice.
Hypernasality deals with __________ not airflow.
Explain cul-de-sac resonance.
- Front end blocked off
- Back end accessible
- Hollow/"jug band" music
How does having cleft palate possibly affect language?
- Syndromes contribute to many of child's problems
- Hearing/otitis media
- Hospitalization/less language rich experience
- Parent maladjustment/may not get out in public
It all depends on how the child was raised...
What evaluation test focuses on * items (sibilants, fricatives...high pressure consonants); could do same thing with picking these out on the Goldman Fristoe.
- Iowa Pressure Articulation Test (IPAT)
- Templin-Darley Test of Articulation
What tests for error patterns and is organized in columns with headings such as nasal emission, velar fricative, nares constriction, pharyngeal fricative)?
Bzock Error Pattern Test
This test is not particularly useful because cleft speech errors are in articulation not phonological (linguistic).
Kahn-Lewis Phonological process
In this test the child says a word such as "beat" over and over with and without nares closed.
- Cul-de-sac hypernasality test
- if cul-de-sac resonance the word will sound changed
What's the treatment or nasal emission that is consistent?
This program affects hypernasality: syllable combinations starting with low oral impedance and then move up the hierarchy to plosives.
Program for Elimination of Hypernasality in Phonetic Contexts
Cleft speech management is based on successive _________.
What are 4 steps to establish correct articulatory placement in response to compensatory errors?
- Pharyngeal flap often gives some instantaneous results
- Greater jaw/oral opening during vowels, glides & liquids decreasing oral impedance
- Lighter articulatory contacts (easy speech) reduces intraoral peak air pressures
- Slow rate of speech creates longer transitions bet/C-V giving velum a beter chance to make contact with pharyngeal wall.
Oral calisthenics/blowing exercises are supposed to help with nasal emission but doesn't really. How can it be used?
- Demonstrates when air comes out mouth vs. air coming out nose.
- Demo this then move to speech
What are 3 forms of biofeedback discussed in class?
- Endoscopy (oral/nasal)
Biofeedback technique using fiberoptic technology so that they can learn to control muscles when they see the effects visually on monitor.
Using this biofeedback device with plate and 2 microphones games can be played. (Birdie in the sky)
This biofeedback tool has a clear vertical tube with a thinner flexible tube that goes in nose. If the plug goes up and down it's an "oops" if it doesn't move, they've got it. Helps post flap surgery to teach them how to use it.
What are 10 people that may serve on a cleft palate team?
- Otolaryngologist (ORL)
- Plastic Surgeon
- General Dentist
- Social Worker
What are the advantages of a cleft palate team?
- Coordinated/comprehensive care
- Travel/appointments minimized
What's a disadvantage of a cleft palate team?
- Family has difficulty relating to all professionals at once
- Social worker or experienced parent can help offset
What are 5 roles of the SLP?
- Evaluate artic/resonance when considering secondary proc.
- Avoid developing "golden ear" syndrome
- Predict speech expectations (adenoids)
- Trial management/decision making
- Post-op evals (hoping for hyponasality)
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