Speech language pathologists working with individuals affected by cleft lip and palate and resonance disorders must be cognizant of how these conditions may alter voice quality, working closely with otolaryngologists and craniofacial teams in order to maximize speech outcomes.
Ideal therapy should seek to establish a balanced ratio between oral and nasal sound energy for each intended speech sound, and this article will present various solutions that may help achieve that aim.
Oral Resonance Therapy (ORT)
SLP (speech-language pathology) services such as screening, assessment, diagnosis and treatment to individuals of all ages suffering from resonance disorders are provided by us. Clients and their families are educated regarding the nature and management of their disorder as we collaborate with physicians and cleft craniofacial teams in identifying causes and providing access to comprehensive services.
Assessing oral, nasal and velopharyngeal (VP) function to produce speech sounds including vowels, voiced oral consonants and palatal consonants; assessing the impact of cleft palate with or without palatal obturator on VP function; and uvulopalatopalatopharyngeal deviance on closure and articulation performance as well as developing plans of treatment or making referrals to ensure access to appropriate medical or surgical intervention are performed successfully.
Resonant Voice Therapy seeks to improve phonation by increasing oral vibratory sensations felt on lips and teeth or higher in the face (mask). Ideally, it should be easy for users to implement. Hypernasality and cul-de-sac resonance often co-exist within an individual with velopharyngeal dysfunction; occasionally these issues may surface separately during connected speech (e.g. during apraxia).
Resonant voice production occurs when sound energy passes from vocal tract to filter and into the velar articulator for enhancement of harmonics based on size and shape of supralaryngeal structures, larynx, nasal cavities and oral cavities. Resonance also is affected by how high or low velum rises during articulation/release action thus altering quality of sounded.
The velum lies directly above the vocal folds and immediately below the pharyngeal sphincter. During normal voicing, its movements help achieve accurate articulation of nasal and non-nasal sounds; its “resonance” with air in the upper respiratory system allows it to resonate during speaking.
An SLP might utilize the resonance questionnaire technique to decrease an excessively high velum. This involves rating several sounds with a specially created scale in order to identify their characteristics – loudness, clarity and pitch in particular – so they can teach their client how to control and intensify articulation for increased sound improvement.
Oral Motor Therapy (OMT)
The orofacial myofunctional therapist uses gentle touch to move soft tissue of the jaw, lips, tongue, palate, cheeks and pharynx in order to restore normal movement patterns necessary for speech production. These movements are initiated by velopharyngeal opening and controlled by articulation muscles – this therapy approach is known as orofacial myofunctional therapy or OMT and forms part of an interdisciplinary treatment of children with cleft palate and craniofacial disorders. An orofacial myofunctional therapist works closely with doctors from multiple disciplines to monitor progress of children and assess when malocclusion can be corrected
Orofacial myofunctional physiotherapists often collaborate with craniofacial teams to assess and treat velopharyngeal dysfunction caused by pathologies like enlarged tonsils or adenoids or conditions impacting nasal patency, including referral of children for further assessment and management by craniofacial/cleft palate teams.
Dependent upon the cause of velopharyngeal dysfunction, speech therapy may provide one or both primary treatments. One such therapy would focus on improving articulation and sound/voice production (for more information see ASHA Practice Portal page on Speech Disorders). This can improve voice quality when there are no structural issues present.
One form of oral motor therapy which may prove useful in treating velopharyngeal conditions is targeted oral motor therapy that targets muscles involved in its function, such as those located in the pharynx, larynx and esophagus and that control velopharyngeal opening position. A trained therapist can teach their patient how to position these muscles for maximum velopharyngeal closure and vocal quality improvement.
Resonant voice therapy works to harness the natural resonances within your vocal tract – comprising cavities like your mouth and throat that shape sound waves to produce clear, strong, powerful voices – by using various techniques that enhance its strength, clarity, power and ease of use with minimal strain or effort, thus minimizing risk of injury. Your therapist will guide you through a series of exercises ranging from feeling vibrations through to producing basic speech gestures, word level phrases or conversational productions.
Nasal Obturator Therapy (NOT)
Velopharyngeus/VPD) can be affected by various external and internal factors. These may include both structural and functional elements present at once. As a result, resonance disorders may interfere with speech production and normal articulation. Speech-language pathologists are trained professionals with unique qualifications to diagnose and treat VPD; additionally they may offer screening/assessment services and therapeutic support as needed.
The incidence and prevalence of these conditions varies greatly based on their etiology; for instance, the incidence of cleft lip and palate is much higher than VPD, which may have various causes; additionally, its causes vary between adults and children as well as between males and females.
Patients undergoing surgical removal of their maxilla due to cancer often remain with large defects that inhibit functionality, esthetics and speech. Rehabilitating such patients can be an intricate process when prosthetic solutions must be found to restore functionality and speech.
An effective solution for restoring function, esthetics and speech is an obturator prosthesis. An obturator provides a means of separating oral and nasal cavities while still preserving anatomy, supporting mandibles and facial tissues as well as reestablishing speech and swallowing functions.
Case report presented of a patient undergoing maxillectomy for squamous cell carcinoma who presented with a large defect following treatment, who was successfully rehabilitated with an artificial hollow bulb obturator provided by the Department of Prosthodontics. This prosthesis was employed alongside speech therapy to maximize rehabilitation success. Interviews were used to collect data on sociodemographics, self-report of obturator functioning using the Obturator Functioning Scale, retention and stability as well as quality of life (QoL). Results revealed that QoL was significantly linked to marital status: married patients reported greater QoL than divorced or widowed patients. This finding illustrates the need for an integrated team approach in rehabilitation of maxillectomy patients with obturators.
Cul-de-sac Therapy
Cul-sac therapy addresses sound becoming trapped as it leaves part of the vocal tract, either structurally (such as with a cleft lip, palate or nasal obstruction) or functionally ( such as issues related to motor planning/execution). This causes speech volume to diminish dramatically while remaining muffled – indicators include weak and unintelligible voices as well as feeling as though your child is “mumbling”, and lack of energy in consonants.
Oral, nasal and pharyngeal resonance can all produce the cul-de-sac effect. Oral resonance occurs due to microstomia while nasal resonance usually involves either narrow nasal passages (stenotic nares) or enlarged tonsils. Pharyngeal cul-de-sac resonance is most frequently caused by VPI with large tonsils or deviated septum with VPI combined; this variation often produces “mixed resonance”, producing hypernasality on oral sounds while hyponasality for nasal sounds.
Phonemic analysis is the ideal way to diagnose this issue. Have your child pronounce various vowels and consonants together (for instance [mmmmmmm], “b-e-d-g”, etc). Listen closely while covering his mouth with your closed fist to hear each sound individually so you can accurately assess if there is an obstruction present or not.
VPI may be present at birth or may result from damage to the throat and nose during infancy due to trauma, surgery or another source.
Research has demonstrated that laparoscopic excision of endometriosis at a specialist center provides effective relief of symptoms; however, in cases with complete obliteration of their cul-de-sacs intestinal surgery may be required to ensure complete removal and prevent future recurrences of disease.
