Question
I have a new student on my caseload. She is 5 years old and was born with a submucous cleft. The cleft has been repaired and she had a pharyngeal flap in November 2004. She did receive speech therapy as a preschooler. According to her previous therapist
Answer
As I read this question I was anticipating just exactly this ending. The kid has had a flap. But her speech still remains un-intelligible due to excess resonance. You are right to be perplexed. The first question is, is the flap still there and doing its job well enough? Flaps do disintegrate, pull out, or otherwise fall apart. I've seen a number of kids where this happened. Get the child scoped. You may not have a scope, but a good ENT should. The surgeon who did the flap should have the means to do this as well. If at all possible, go with the child to this appointment. First and foremost determine if the flap is present, and then if it is adequate. No matter how good of a teacher you are, you can't teach the tissue to grow. You can't teach the muscles to be there or to be adequate.
If the flap isn't there or isn't adequate more surgery is needed. We recently saw a young man in our clinic whose "flap" had been re-constructed from lateral pharyngeal wall tissue. (The first flap came from posterior pharyngeal wall tissue, which is the most typical flap procedure.) We had to send him across the state as no one in our area did this relatively more complicated procedure. For the first time in his life, he had control over the velopharyngeal port. Having the possibility of adequate closure is the job of a construction crewsurgeonnot a teacher or speech therapist.
Once you know the child has adequate structure there are a number of strategies for teaching the child to use the mechanism appropriately. Kuehn and Henne (2003) have a great article in the American Journal of Speech-Language Pathology 12 (1), 103-109, titled, Speech evaluation and treatment for patients with cleft palate. I like the article by Kummer and Lee (1996) in Language, Speech, and Hearing Services in Schools 27 (3), 271-281 titled, Evaluation and treatment of resonance disorders.
Dr. Cheryl B. Gerard teaches at Minot State University in Minot, North Dakota in the area of cleft palate and augmentative communication. She serves the community as the Speech Language Pathologist for the Minot Cleft Palate Team and the Minot Child Disability Clinic.
