Question
I work with a 3 year old girl with Pierre-Robin Sequence, who is 2 years post cleft repair. She is cognitively very bright and has excellent speech and language skills. Her compensatory speech errors (snorting of fricatives) have been corrected (approx. 6
Answer
Nasal turbulence, also called a nasal rustle, is due to air pressure being forced through a small velopharyngeal opening. As the air pressure goes through, there is friction and bubbling of secretions above the opening. The bubbling is what you actually hear in speech.
Therapy works best for patients who have compensatory articulation errors or phoneme-specific nasal emission (which is due to faulty articulation). It does not work well with structural deficits that are typical with a history of cleft palate for obvious reasons. With therapy, making the child aware of the nasal emission can often eliminate it temporarily. However, my experience is that the correction doesn't last because it takes additional muscular effort. In most cases, surgical correction is indicated for permanent correction.
Very large tonsils can interfere with velopharyngeal closure if they extend behind the posterior faucial pillars. In this case, they may interfere with lateral pharyngeal wall movement or even extend up into the nasopharynx to become interposed between the velum and posterior pharyngeal wall. A tonsillectomy will correct this. If secondary surgical intervention is needed for VPI, then the tonsils often have to be removed anyway to prevent airway obstruction postoperatively.
At our velopharyngeal dysfunction clinic, we routinely do nasopharyngoscopies on three year olds. I would recommend nasopharyngoscopy in this case prior to doing additional therapy. If there is a small gap, which is usually the case with turbulence/rustle, it is important to know where the gap is and what is contributing to it to determine the appropriate method of treatment (tonsillectomy, pharyngeal flap, sphincteroplasty, pharyngeal augmentation, etc.). The bottom line is that speech therapy will not correct a structural defect and if that is the cause of the nasal emission, surgical correction is indicated.
Dr. Kummer is director of speech pathology at Cincinnati Children's Hospital Medical Center, and Clinical Professor of Pediatrics at University of Cincinnati Medical Center. She has been a member of the Craniofacial Anomaly Team for 25 years and is the author of the text entitled: Cleft Palate and Craniofacial Anomalies: The Effects on Speech and Resonance, Delmar-Thomson Learning, 2001.