Therapy for Velopharyngeal Dysfunction

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Answer

Before a treatment program can be designed for this child, there are several questions that need answers. The first two questions are these: how was the diagnosis made, and who made the diagnosis? In order to answer these, I would recommend that you ask the parents to sign a release allowing you to request records from the professional who made the diagnosis. "Weak velopharyngeal closure" is rather vague, and does not tell us much about what we have to work with in therapy. A vague diagnosis is unfortunately suggestive of vague knowledge of velopharyngeal function. Many community ENT physicians are excellent doctors, but may not have much knowledge or experience with the velopharynx as it functions for speech.

Once you have received the records, look to see what kind of assessment was used to make the diagnosis. Imaging assessments, such as nasopharyngoscopy or speech videofluoroscopy give us pictures of the mechanism as it functions. Other instrumental assessments, such as pressure-flow measurements or Nasometry, yield data from which we can infer velopharyngeal function. In order for any of these tests to be considered valid, the examiner must use oral articulation productions. Glottal stops, nasal fricatives, pharyngeal fricatives, and nasal consonants yield spurious data in a diagnostic exam for velopharyngeal dysfunction, and if the diagnosis results from any of those articulations, the assessment may not be valid. Well-intentioned ENT physicians may put a scope in the child's nose and ask the child to repeat syllables or words, but if they do not understand the articulation patterns, they may not be giving a good assessment.

If the assessment was conducted by the velopharyngeal specialists from a cleft palate or craniofacial team, the assessment is more likely to be valid. In that case, you may want to obtain a release from the parents to talk with the speech pathologist involved with that team. Find out what recommendations he or she might have for this particular child.

A third, and most important question to be answered before treatment begins, is, "What is the child's articulation skill?" This assessment must be done carefully. Use the articulation test of your choice. Pay careful attention to articulatory gestures and distortions. Next, repeat the articulation test with the nose plugged. If an articulation is normal, but weakened or distorted by a nasal air leak, it will normalize when the nose is plugged. Once you document normal articulations in a single word task, follow them up into more complex utterances to see if they stay normal, or if the articulation changes as complexity increases. (For example, if the child produces normal sounding [p,b] with the nose plugged in "bubble" and "puppy," does he also do so in, "Pop a big bubble" and "Buy Bobby a puppy?" If the articulation deteriorates with increased complexity, you will need to address this in therapy.

If an articulation does not sound normal with the nose plugged, the error cannot be attributed to nasal air escape, and you will need to identify and describe the misarticulation. For example, if [p,b] do not normalize with nose-plugging, and the child appears to be approximating bilabial closure, he or she may be posturing with the lips but actually articulating at the glottis. If you only get a posterior click when you try [s,z] with the nose plugged, the child may be substituting a nasal fricative (deliberate forcing of air through the nose) for an oral [s,z]. If you find abnormal articulations, you will need to treat them. Not only will this improve the child's intelligibility, but it will also prepare the child for valid velopharyngeal assessment if needed.

Once you identify your articulation targets, try to schedule the child for individual articulation therapy. Some of the techniques you may be using will likely be different from the techniques used for others on your caseload, so group therapy may not be effective for this child. Avoid "oral motor" treatment programs that use non-speech tasks to treat speech disorders. These are generally not effective for improving velopharyngeal function for speech, and if the child needs to learn appropriate oral articulation, you will need to teach it. Likewise, language-based phonological approaches are usually ineffectual in these circumstances.

Good information on treatment of speech disorders related to velopharyngeal dysfunction can be found in "Therapy Techniques for Cleft Palate Speech and Related Disorders," by Karen Golding-Kushner, (2001), published by Singular. There are several other references listed at the conclusion of my comments that you may find useful as well.

My suspicion is that the whispering while singing songs was an ineffectual treatment, and may have resulted from a misunderstanding of a suggested technique for eradication of inappropriate glottal stop articulation. If a child is substituting a glottal stop for an oral stop, for example, a [t], you will need to teach appropriate placement and production of the [t]. Whispering is a technique that can be used, because of the configuration of the vocal folds, to "turn off" the glottal stop when you are trying to teach the oral consonant in isolation. Once you have established the oral consonant production in isolation, you usually do not need to continue the whispering You do need to gradually advance the oral consonant into progressively more complex usages: syllables, then imitated words, phrases, etc. until the appropriate consonant is consistently used.

Nasal emission or nasalization on appropriately-articulated consonants (verify this by plugging the nose) is considered an "obligatory error." This means that the air escapes from the nose even though the child is doing all the right things otherwise. This is a sign that the child would likely benefit from some form of surgical or prosthetic velopharyngeal management. To initiate that process, the child will need to be evaluated by specialists in hypernasal speech, usually physicians and speech pathologists associated with a cleft palate team. To locate a cleft palate team near you, call 1-800-24-CLEFT, the information service of the Cleft Palate Foundation, or visit their website at www.cleftline.org.

References:

Clark, H.M. (2003). Neuromuscular treatments for speech and swallowing: a tutorial. American Journal of Speech-Language Pathology, 12, 400-415.

Golding-Kushner, K.J. (2001) Therapy techniques for cleft palate speech and related disorders. San Diego: Singular.

Kummer, A.W. (2001) Cleft palate and craniofacial anomalies: effects on speech and resonance. San Diego; Singular.

Peterson-Falzone, S.J. (1986) Speech characteristics: updating clinical decisions. Seminars in Speech and Language, 7, 269-295.

Ruscello, D.M. (1984) Motor learning as a model for articulation instruction. In J. Costello (Ed.), Speech disorders in children. San Diego: College Hill Press.

Ruscello, D.M. (1993). A motor skill learning treatment program for sound system disorders. Seminars in Speech and Language, 14, 106-118.

Trost, J.E. (1981) Articulation additions to the classical description of the speech of persons with cleft palate. Cleft Palate Journal. 18: 193-203.

Lynn Marty Grames, MA, CCC-SLP, has been a team member of the Cleft Palate and Craniofacial Deformities Institute at St. Louis Children's Hospital since 1982. Her practice with the Institute focuses on cleft palate/craniofacial diagnostics, therapy, and clinical research.