Hypernasality in the Absence of Cleft

Question

I am an SLP who works mainly with adults in the hospital setting. I am also starting to treat children privately for primarily articulation problems. Recently, a mom in my community has been asking me many questions about her 5-year old daughter who is hy

Answer

The combination of hypernasality, a tongue forward rest posture, speech errors and possible language delay suggests the need for a thorough speech and language evaluation. In addition to using whatever formalized testing that may be preferred, some additional observations and suggestions are warranted:

1. Oral diadochokinesis. One of the first things I would assess is the child's ability to perform on a oral diadochokinetic test. Rather than stare at the stopwatch during the evaluation, I would, instead, recommend focusing on the movement pattern of the tongue. Because of the tongue thrust and forward rest posture of the tongue, I would suspect a forward thrust pattern of the tongue for productions that would normally require an elevation of the tonguetip. This child likely has a rudimentary ability to control a flaccid tongue, and this would result in horizontal rather than vertical movements of the tongue during oral diadochokinesis. During the "tuh's", you may observe that the mandible moves vertically on each repetition. To eliminate the mandibular assist, have the child bite on a tongueblade inserted at the corner of the mouth back to the molars. Biting on the tongueblade permits evaluation of whether there is any ability to elevate the tongue tip during rapid, repeated "tuh's". I suspect that this child has a neuromotor delay for speech which results in a forward posturing and movement of the tongue. The "pocketing" of food is also consist with this suspicion.
   
   
2. Evaluating hypernasality. In the absence of instrumental armamentaria to evaluate hypernasality and velopharyngeal closure, the SLP can estimate a child's ability to decrease hypernasality in speech therapy. This is done by having the child count normally, 1 to 10 or 20, then have him/her repeat the counting while overexaggerating anterior oral movements. The principle here is that the oral ring of muscles exerts a reciprocal control over the nasopharyngeal ring of muscles. If exaggerated anterior oral movements during counting do not reveal a reduction in the level of hypernasality in the voice, speech therapy will not be effective and a referral for physical management is appropriate. An additional screening device is to modify pitch, up and down, to evaluate whether this modifies the level of hypernasality in the voice.
   
   
3. Physical management of hypernasality. You mentioned the possibility of a palatal lift speech appliance. This suggestion is not a likely possibility for a five year old. The 6 year molars are needed for retention of the appliance, as is compliance for wearing and managing a prosthesis; not typically found in a 5 year old. The procedure of choice is a posterior pharyngoplasty, such as a sphincter pharyngoplasty, pharyngeal flap, or Furlow palatoplasty.
   
   
4. Referral information reminders. If this child is referred for physical management of hypernasality, please remember, in reports to dentists and physicians, to mention oral diadochokinetic testing. You will recall that diadochokinetic testing was developed in medicine as a test for cerebellar competence using rapid repetitions of the fingers, so the inclusion of oral clarifies what you have done. Also, in reporting examination findings, please avoid saying "oral-peripheral" (peripheral to what? did you test all peripheral nerves?), The preferred, accurate term is orofacial examination. (Thanks for helping me stamp out this inaccurate anomaly in SLP decriptions).

The reddish spot just under the nose that the mother reports is not consistent with a submucous cleft of the palate nor a sub-clinical cleft lip. A plastic surgeon would be well trained to evaluate this, and I would accept his/her perception of this as a non-issue. If the reddish spot was on the lip itself, I might suspect a lip pit which can be a genetic marker for a syndrome associated with cleft lip, with or without cleft palate (Van Der Woude syndrome). So overall, I think the focus with the child described in your question should be on maturational delays rather than a physical association with a red spot below the nose and hypernasality. This child would appear to be a good candidate for your envisioned private practice with articulation and language problems. Good luck.

Robert M. Mason, DMD, Ph.D. is a speech-language pathologist (CCC-ASHA Fellow), a dentist, and orthodontist. He is a Past President of the American Cleft Palate-Craniofacial Association, a professional, interdisciplinary organization specializing in problems associated with facial and oral deformities. Dr. Mason has studied and written extensively about orofacial evaluations, developmental problems related to the tongue, and the anatomy and physiology of the speech and hearing mechanisms. His reports have appeared in speech, dental, medical, and plastic surgical journals and texts. He is considered to be an expert in tongue thrusting, tongue tie, and other problems related to tongue functions and speech.