Craniofacial

Question 1

What misarticulations might falsely appear as “inconsistent velopharyngeal closure” on imaging studies?

Answer 1

Glottal stop substitutions, nasalization of vowels, nasal fricatives substitutions, and pharyngeal fricatives.

Question 2

If a child has a repaired CP and presents with pharyngeal fricatives, what could you use as treatment to target this sound?

Answer 2

Auditory discrimination, teach place of articulation, shaping (long t) and VC syllables.

Question 3

How would you decide what VP managment to use?

Answer 3

determine cause, hear patient’s wishes, assess velo-pharyngeal function, etc…

Question 4

What signs might you see if a patient had a repaired CP?

Answer 4

“z” scar or some scar on the roof of the mouth, hypernasality, weak pressure consonants, nasal emissions, compensatory behaviors, etc…

Question 5

How would you explain nasometry to a surgeon and what are it’s limitations?

Answer 5

Nasometry assesses VPI indirectly by acoustic measurements. Doesn’t tell us why it is happening. It’s limited because it cannot be used on its own to assess VPI.

Question 6

Explain why someone might be a candidate for a pharyngeal flap vs. palate re-repair for VPI?

Answer 6

Re-repair: No prior surgeries (DOZ/IVV), limited velar movement.

Pharyngeal Flap: Have had DOZ or IVV, good lateral pharyngeal wall movement, not good velar movement, and has a big VP gap.

Question 7

What is the SLP’s job before palate repair?

Answer 7

Should meet for the first time around 3 mo. to discuss S+L development, provide parent education on S+L norms, help parents improve their child’s speech, and explain why they are doing what they are doing.

Question 8

Describe the possible configurations of CLP to a parent who is expecting.

Answer 8

CLO - A cleft in the lip that can be bilateral or unilateral and may extend up to the nose. The roof of the mouth is not affected, and feeding and speech usually develop well post-surgery.

CPO - The lip is intact, but the roof of the mouth contains a cleft. Can be complete (thru both alveolus and palate) or incomplete (alveolus only). Can affect feeding, hearing, and speech. Can be repaired and addressed with speech therapy.

CLP - There is a cleft in both the lip and palate. Can be unilateral or bilateral, complete or incomplete. Can affect feeding, hearing, and speech. Can be repaired and addressed with speech therapy. (Lip/nose first then palate later one)

SMCP - Hidden cleft (usually inverted ‘v’ shape) of the muscles in the soft palate. Tthe mucous membrane covering the roof of the mouth is intact, but the underlying muscles haven’t joined properly, which can cause VPI. Red flags for this: hypernasality, weak pressure consonants, nasal emissions, a bifid uvula, and the lack of a palatal notch on the roof of the mouth.

Question 9

When would you consider an obturator for a patient with a fistula?

Answer 9

The patient doesn’t want surgery, can be used while waiting for repair, not a surgical candidate, significant nasal emissionhypernasality, regurgitation of food and liquid due to fistula.

Question 10

Your infant patient who has Pierre Robin Sequence + CPO has airway issues. What bottle + positioning would you use and why?

Answer 10

45-degree angle and on the side due to a small mandible. could start with infant paced bottle (Pigeon/Dr. Brown’s) on non cleft side (if applicable) or if has no suck, use an caregiver assisted bottle (Haberman/Johnson Mead) to help pace.

Question 11

If a child has a repaired CP and presents with pharyngeal fricatives, what could you use as treatment to target this sound?

Answer 11

Using “long t,” emphasize place and production, and using VC syllables.

Question 12

How would you decide what VP management to use for CP?

Answer 12

Identify the cause of VP, assess with nasopharyngoscopy or videofluoroscopy, and decide if treatment is surgical (Re-repair (DOZ)/Pharyngeal Flap/ Sphincter), prosthetic (Obtruator), or behavioral (Speech therapy).

Question 13

Explain why someone might be a candidate for a pharyngeal flap vs. palate re-repair vs. sphincter?

Answer 13

Re-repair: No prior surgeries (DOZ/IVV), limited velar movement.

Pharyngeal Flap: Has had DOZ or IVV, good lateral pharyngeal wall movement, not good velar movement, and has a big VP gap.

Sphincter: Has had DOZ or IVV, good velar movement, with or without good lateral pharyngeal wall movement.

Question 14

What should an SLP do if a child has hypernasal speech?

Answer 14

Assess resonance across different phonemes, consistent vs. inconsistent hypernasality, check for nasal emission (obligatory/learned), check for compensatory artic errors (glottal stops, pharyngeal fricatives…), Can you feel nasal vibrations on sustained vowel productions? Is there a resonance shift heard between nares-closed and nares-open vowel productions? Check stimulability, refer if surgical intervention is needed.

Question 15

What are the signs you might see in a patient if they had VPI following a cleft palate repair?

Answer 15

Hypernasality, weak pressure consonants, nasal air emissions (obligatory/learned), compensatory artic behaviors (glottal stops, pharyngeal fricatives…), nasal grimacing, and unintentional fistula.

Question 16

What would you say to a parent about what to expect in an infant with a possible CL/P?

Answer 16

Could have feeding difficulties depending on severity, could need speech therapy depending on CLO or CL/P, An interdisciplinary approach is used, lip and nose surgery done around 3~ mo., palate surgery done around 9-12 mo. bone graft done based on dental age, but typically around 6-8 yrs. Can live a normal and functional life with therapy and early intervention.

Question 17

What are some examples of speech sound errors that an SLP can treat in a child with cleft, and what cannot be treated by SLPs?

Answer 17

CAN - Glottal stops (/p/, /t/, /k/), Pharyngeal fricatives, Posterior nasal fricatives, Mid dorsom palatal stops, ingressive airflow and omissions.

CANNOT - Hypernasality (directly), errors due to fistula, VPI, and nasal emissions.

Question 18

An infant with BCLP cannot lach properly and has no suck. What bottle could you use and why?

Answer 18

Caregiver-assisted bottle (Habermen $$$ /Johnson Mead $ ) allows for controlled flow and (For Haberman) has longer nipple to help bypass cleft and reduce nasal regurgitation.

Question 19

How might you use assessment tools (Ex. nasometer, nasopharyngoscopy, or videofluoroscopy) during treatment?

Answer 19

Nasometer - offers acoustic measures to go along with clinical judgment of resonance. Can provide some biofeed back and supplament data.

Nasopharyngoscopy - Flexible scope through the nose to see the velopharyngeal mechanism during speech. Provides biofeedback. Guides whether surgery, prosthetics, or therapy is most appropriate

Videofluoroscopy - A dynamic, side-view X-ray of the velopharyngeal port in motion during connected speech. Visualizes movement of the soft palate and pharyngeal walls.

Question 20

What can you do as an SLP before CLP surgery to improve speech outcomes afterward?

Answer 20

Encourage lots of vocal play and early babbling, model sounds with strong oral pressure like /b/, /m/, /d/, /g/, model sounds the child already has that are correct, discourage reinforcing compensatory sounds, teach parents about typical speech and language development so they know what to expect.

Question 21

Explain the signs of SMCP (Submucous cleft palate) to your SLP colleague in the schools.

Answer 21

Submucous cleft palate is a hidden cleft (usually inverted ‘v’ shape) of the muscles in the soft palate. Unlike an overt cleft, the mucous membrane covering the roof of the mouth is intact, so it’s not always visible, but the underlying muscles haven’t joined properly, which can cause problems with velopharyngeal closure during speech. Red flags for this can be hypernasality, weak pressure consonants, nasal emissions, a bifid uvula, and the lack of a palatal notch on the roof of the mouth.

Question 22

At what age would you expect bone grafting, and how might setting up for that influence speech?

Answer 22

Typically performed at around 7 to 9 years of age (But based on dental age). The ideal timing is just before the eruption of the permanent canine tooth, to ensure that the tooth erupts into the newly grafted bone, helping to stabilize the dental arch.

If a fistula is created or closed, it could affect speech. (Hypernasality/nasal emission) Compensatory behaviors could affect speech.

Question 23

How would you test for obligatory vs. learned nasal emissions?

Answer 23

Ask the child to produce pressure sounds like:/p, b, t, d, s, z, f, v, k, g/, check structures for obligatory emissions, look for PSNE, close the nares to see if nasal emissions stop or continue during nasal sounds, and check stimulability.

Question 24

You have a student who presents with speech errors on /f/ and /v/because of missing dentition. How would you determine whether or not to proceed with speech treatment?

Answer 24

Is the error developmental, compensatory, or strictly due to missing dentition? Is the student distorting the sound? (e.g., less precise but still recognizable) Or is it a complete substitution or omission? Consider developmental norms and age, check stimulability, is there an underlying condition or irregular dentition? (malocclusion, cleft palate, etc…)

Question 25

Why is CPAP therapy not considered NSOMT? In what cases would you consider using it for VPI?

Answer 25

NSOMT refers to non-speech oral motor exercises—like blowing, sucking, or puffing cheeks—used in hopes of improving speech sound production. These are controversial because research shows they do not generalize to speech, which requires different neuromotor control. CPAP is not NSOMT because: It involves speech production tasks (e.g., repeating pressure consonants) during therapy. It directly targets velopharyngeal closure during speech, not isolated oral motor strength. CPAP might be used in select cases where: Surgical repair has been done, and the child continues to demonstrate mild to moderate hypernasality without overt structural insufficiency, and traditional speech therapy alone has not resolved the hypernasality, and further surgery is not currently planned or recommended.

Question 26

A parent of an infant with an unrepaired CP is struggling to feed their baby within a 30-minute period using a Haberman bottle. What would you recommend at the SLP?

Answer 26

Check bottle flow rate, ensure the nipple is oriented correctly, optimize positioning (45 degrees), monitor suction and compression, teach pacing and breaks, or change bottle if needed (Johnson Mead or move to Infant paced)

Question 27

Explain the differences between obligatory nasal emissions and learned nasal emissions.

Answer 27

Obligatory Nasal Emissions - Due to a structural problem, caused by VPI or fistula, cannot be fixed with speech therapy alone. Learned Nasal Emissions - Due to a misarticulation or compensatory habit (not structural) Ex: producing /s/ with nasal airflow due to a previous history of VPI or habit formation. Often stimulable, Nasal airflow occurs on certain sounds, but not consistently,and can be treated with speech therapy

Question 28

What are considered roles of the SLP in prosthetic management of VPI?

Answer 28

Be present during each "add on" session to complete perceptual speech assessment, provide patient and family education and counseling, work with the prosthodontist throughout initial assessment, fitting of the prosthesis, and follow-up process, and recommend what intervention (Ex. palatal lift) would be most appropriate.

Question 29

Explain to a colleague the difference between ingressive airflow and nasal emission.

Answer 29

Ingressive airflow is speech done on the inhale as a compensatory strategy and is not related to VPI. Nasal emission is the audible or inaudible release of air through the nose during pressure consonants (/p/b/s/t/) and is caused by VPI.