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Speech Evaluation for Patients with Cleft Palate

Article  in  Clinics in plastic surgery · April 2014

DOI: 10.1016/j.cps.2013.12.004 · Source: PubMed

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Ann W Kummer
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Speech Evaluation for Patients
with Cleft Palate
Ann W. Kummer, PhD, CCC-SLP

KEYWORDS
 Velopharyngeal insufficiency  Velopharyngeal incompetence  Velopharyngeal mislearning
 Velopharyngeal dysfunction  Hypernasality  Nasal emission  Nasopharyngoscopy  Nasometry

KEY POINTS
 Resonance disorders are common in children with a history of cleft palate. There may be hyperna-
sality caused by velopharyngeal insufficiency (VPI). There may also be hyponasality or cul-de-sac
resonance caused by obstruction in the vocal tract.
 Speech disorders are common in children with a history of cleft palate. There may be compensatory
articulation productions caused by VPI or even caused by malocclusion if there was also a cleft of
the primary palate.
 Differential diagnosis of the cause of hypernasality and/or nasal emission and also of abnormal
speech sound production is critical in determining appropriate treatment (eg, surgery, speech ther-
apy, or both).
 VPI is a structural abnormality and therefore requires surgical management.
 Velopharyngeal mislearning (including the use of compensatory productions caused by VPI or a his-
tory of VPI) is a functional disorder that requires speech therapy.

Videos of a speech sample, evaluation of nasal emission using a straw, oral examination, nasometry,
and nasopharyngoscopy accompany this article

ANATOMY AND PHYSIOLOGY OF THE in a superior and posterior direction to close firmly
VELOPHARYNGEAL VALVE against the posterior pharyngeal wall (or adenoids
in young children) (Fig. 2). At the same time, the
The velopharyngeal valve consists of the velum lateral pharyngeal walls move medially to close
(soft palate), the lateral pharyngeal walls, and the against the velum, or in some cases just behind
posterior pharyngeal wall. These structures work the velum. Complete closure of the velopharyngeal
in concert to open and close the velopharyngeal valve is required for all vowels and most conso-
valve during speech. nants. The exception is with the production of
During nasal breathing, the velopharyngeal nasal sounds (m, n, ng), for which the velopharyng-
valve is open. The velum rests against the base eal valve is completely open to allow nasal reso-
of the tongue and the lateral pharyngeal walls are nance. In connected speech, the velopharyngeal
wide apart (Fig. 1). This arrangement provides a valve therefore opens and closes throughout an
patent upper airway for unobstructed nasal utterance based on the type of speech sound
breathing. During oral speech, the velum moves (oral or nasal) that is produced.
plasticsurgery.theclinics.com

Disclosures: The author receives royalties for the following textbook: Kummer A.W. Cleft palate and craniofacial
anomalies: effects on speech and resonance. 3rd edition. Clifton Park, NY: Cengage Learning; 2014. The author
receives royalties for the Nasoscope clinical device, marketed as the Oral & Nasal Listener, Super Duper, Inc.
Division of Speech-Language Pathology, Cincinnati Children’s Hospital Medical Center, MLC 4011, 3333 Burnet
Avenue, Cincinnati, OH 45229-3039, USA
E-mail address: [email protected]

Clin Plastic Surg 41 (2014) 241–251

http://dx.doi.org/10.1016/j.cps.2013.12.004
0094-1298/14/$ – see front matter Ó 2014 Elsevier Inc. All rights reserved.
242 Kummer

Fig. 1. Normal velar position during nasal breathing.

(From Kummer AW. Cleft Palate & Craniofacial Anom-
alies, 3E. Ó 2014 Delmar Learning, a part of Cengage Fig. 2. Normal velopharyngeal function during oral
Learning, Inc. Reproduced by permission.) speech. (From Kummer AW. Cleft Palate & Craniofa-
cial Anomalies, 3E. Ó 2014 Delmar Learning, a part
of Cengage Learning, Inc. Reproduced by permission.)

Fig. 3. Velopharyngeal insufficiency. Velopharyngeal Fig. 4. Velopharyngeal incompetence. Velopharyng-

insufficiency is caused by a structural cause. In this eal incompetence is caused by a neuromotor disorder.
case, the velum has normal movement, but is too short In this case, the velum is normal in structure, but does
to achieve velopharyngeal closure. (From Kummer AW. not move well enough to achieve velopharyngeal
Cleft Palate & Craniofacial Anomalies, 3E. Ó 2014 closure. (From Kummer AW. Cleft Palate & Craniofa-
Delmar Learning, a part of Cengage Learning, Inc. cial Anomalies, 3E. Ó 2014 Delmar Learning, a part
Reproduced by permission.) of Cengage Learning, Inc. Reproduced by permission.)

VELOPHARYNGEAL DYSFUNCTION VPD.1–5 For example, velopharyngeal insufficiency

(VPI) is most often used to describe a structural
Normal velopharyngeal function depends on 3 defect that prevents complete velopharyngeal
basic components: normal structure (anatomy), closure (Fig. 3). Velopharyngeal insufficiency is
normal movement (neurophysiology), and normal the most common type of VPD because it can be
articulation learning.1 caused by a history of cleft palate or submucous
When the velopharyngeal valve does not close cleft. In contrast, velopharyngeal incompetence
consistently or completely during the production (also abbreviated as VPI) is used to refer to a
of oral sounds, this is often called velopharyngeal neurophysiologic disorder in which poor move-
dysfunction (VPD). VPD is used as a general term ment of the velopharyngeal structures results in
that encompasses disorders of any of the 3 basic incomplete velopharyngeal closure (Fig. 4). Finally,
components of velopharyngeal function (structure, velopharyngeal mislearning refers to an articula-
function, and learning).1,2 Other terms are used for tion disorder in which speech sounds are inappro-
more specificity as to the type and causation of priately produced in the pharynx. As a result of this
 Speech Evaluation in Cleft Palate 243

placement, the velopharyngeal valve is open, thus the speech pathologist must determine the type
mimicking VPI during attempted production of (eg, hypernasal, hyponasal, cul-de-sac, or mixed).
certain speech. This distinction is of utmost importance because
the type of resonance determines appropriate
PERCEPTUAL EVALUATION OF treatment.9,10
VELOPHARYNGEAL FUNCTION Patients with cleft palate often have hypernasal
speech. Hypernasality is characterized by excess
A speech pathology evaluation is indicated for all sound in the nasal cavity during the production
children with a history of cleft palate, particularly of oral sounds. The speech is perceived as low in
to rule out VPI.2,6–11 Although language develop- intensity, muffled, and unclear. Hypernasality is
ment is assessed at a younger age, the speech most perceptible on vowels, which are normally
evaluation for VPI is best done when the child has produced by altering oral resonance. There may
some connected speech and also at a time when also be nasalization of voiced consonants, so
the airway is adequate for secondary surgery, if that oral phonemes (speech sounds) are perceived
needed. For most children, this is around the age to be more like their nasal cognates (eg, m/b, n/d,
of 3 years. A speech evaluation is also indicated ng/g). As a general rule, if nasal phonemes are
both before and after secondary surgery for VPI. heard more frequently than normal, or if nasal pho-
The assessment of velopharyngeal function be- nemes are substituted for oral phonemes, the
gins with a perceptual evaluation of the patient’s resonance is hypernasal and VPI should be
speech. During this evaluation, the examiner ana- strongly suspected.
lyzes the acoustic product of velopharyngeal func- Because resonance disorders are not mutually
tion in order to make inferences about the function exclusive, the speech pathologist assesses for
of the velopharyngeal valve. other types of resonance deviations, which are
also common in patients with cleft palate. For
Speech Samples
example, there may be hypernasality on oral
When assessing speech, resonance, and velo- sounds caused by VPI but also hyponasality on
pharyngeal function, it is important to select an nasal sounds caused by a blockage in the phar-
appropriate speech sample in order to obtain ynx. Hypernasality caused by VPI can also occur
adequate information for a definitive diag- in combination with cul-de-sac resonance, which
nosis.7,9,10 The speech samples used to assess is the result of blockage at the exit of one of the
children with suspected VPD need to be develop- resonating cavities (pharyngeal, oral cavity, or
mentally appropriate in terms of both articulation nasal cavity).
and language. Standardized (norm-referenced) Although hypernasality is most commonly
articulation tests are available for comprehensive caused by VPI, it can also be caused by other fac-
assessment of speech sound errors. In addition, tors, including a thin velum or a large oronasal fis-
the examiner usually elicits a variety of other tula. Hypernasality can even be phoneme-specific
speech samples, based on the child’s language because of the substitution of nasal sounds for
developmental level and what is suspected. These oral sounds (ie, ng/l or ng/r) or habitual use of a
samples may include repetitive syllables (with high posterior tongue position on certain vowels.
pressure-sensitive consonants combined with Hyponasality is also commonly noted in patients
both low and high vowels), rote speech (ie, count- with cleft lip/palate. This condition may be caused
ing), phonetically loaded sentences (eg, Take by a maxillary retrusion, a narrow pharynx, or even
teddy to town), and spontaneous speech. When enlarged adenoids. Postoperative hyponasality is
errors are noted, the examiner typically does also a risk of surgeries to correct VPI.
more focused testing, including tests of
stimulability. Nasal emission
Patients with a history of cleft palate often have
What is Assessed nasal emission. Nasal emission can occur with hy-
The perceptual evaluation includes an analysis of pernasality, if the velopharyngeal gap is large, or
various components of speech, including reso- without hypernasality, if the gap is small.1,6–10,12,13
nance, oral air pressure and nasal emission, The relative audibility of the nasal emission can
speech sound production, and phonation.7,9–11 give a clue as to the size of the velopharyngeal
These components are further described later. opening. Nasal emission that is barely audible (or
inaudible but causes consonants to be weak in
Resonance intensity or omitted) suggests a large velopharyng-
Resonance is typically evaluated by listening to eal gap. A smaller velopharyngeal opening causes
connected speech. If there is abnormal resonance, more audible nasal emission than a large one
244 Kummer

because there is more resistance to the flow, and  Compensatory articulation errors occur when
therefore more friction. Air that flows through a the placement of production is altered in
small velopharyngeal opening is released with response to the abnormal structure. When
increased pressure, which causes bubbling of se- VPI causes inadequate oral airflow for conso-
cretions on top of the valve. The result is a loud nants, the patient may compensate by pro-
and distorting nasal rustle (also called nasal ducing the sounds in the pharynx, where
turbulence).1,10,12,14 there is airflow.11
If present, the examiner notes the occurrence of
a nasal snort, which is produced most often with It is important to determine the cause of each er-
/s/ blends, and/or a nasal sniff, which is a friction ror or distortion, and particularly to identify obliga-
sound that is produced by forcible inspiration. A tory distortions versus compensatory errors. This
nasal grimace commonly accompanies nasal air is important because the treatment is different de-
emission. This observation is important because pending on causality. For example, obligatory dis-
it reflects the patient’s extra effort in attempting tortions do not require speech therapy. Once the
to close the velopharyngeal port. structure is corrected, the distortion disappears.
The consistency of the nasal air emission is In contrast, compensatory errors require speech
also tested. Nasal emission that occurs during therapy, preferably after correction of the structure.
the production of all pressure-sensitive pho-
Phonation
nemes suggests a large velopharyngeal opening,
particularly if it is associated with hypernasality. Dysphonia is common in individuals with VPI. In
Nasal emission that occurs inconsistently, but particular, vocal nodules often occur in patients
on all pressure-sensitive phonemes, suggests a with a small velopharyngeal gap or a nasal
smaller opening because the patient can close grimace. This condition is thought to be caused
the gap with short utterances or with effort. In by strain in the entire vocal tract with attempts to
contrast, nasal emission that occurs consistently achieve velopharyngeal closure. In addition,
on certain speech phonemes, but not on all breathiness is sometimes used as a compensatory
pressure-sensitive sounds, indicates that the strategy to mask the hypernasality or to mitigate
cause is faulty articulation placement rather the nasal emission. In addition, patients with VPI
than VPI. This finding is sometimes noted in pa- secondary to a craniofacial syndrome are at higher
tients with no history of cleft or VPI. It is also com- risk for laryngeal anomalies. Therefore, the speech
mon in patients with a history of VPI who used pathologist listens for characteristics of dysphonia,
pharyngeal fricatives as a compensatory produc- including hoarseness, breathiness, roughness,
tion for certain phonemes. Despite surgical glottal fry, hard glottal attack, strain, inappropriate
correction of the VPI, nasal emission (and some- pitch level, restricted pitch range, diplophonia, or
times hypernasality) persists because of the inappropriate loudness. When present, these find-
abnormal placement. ings are often rated on a severity scale from mild to
severe using the Consensus Auditory-Perceptual
Speech sound production Evaluation of Voice (CAPE-V).15
In assessing articulation (speech sound produc-
Low-technology Tools for the Assessment
tion), the speech pathologist records all speech
sound errors, including substitutions, omissions, There are a few low-technology tools that can be
and distortions. The potential cause of the errors used to assist with the evaluation.7,9,10 The most
is also identified (eg, abnormal structure, apraxia common are discussed here.
[a motor speech sound disorder], phonological
disorder, delayed development, or normal devel- Mirror
opmental error). When there are structural anoma- The examiner can place a dental mirror under the
lies, such as VPI or occlusal anomalies secondary child’s nares while the child produces pressure-
to cleft lip and palate, the speech pathologist also sensitive oral sounds (Fig. 5). If the mirror fogs, it
determines whether there are any obligatory dis- indicates nasal air emission. A problem with this
tortions or compensatory articulation errors.1,9,10 test is that the mirror needs to be placed under
the nose after the individual starts speaking and
 Obligatory distortions occur when the articu- removed before the individual stops speaking to
lation placement (the function) is normal, but avoid fogging as a result of nasal breathing.
the abnormality of the structure causes distor- Another disadvantage is that there is no way to
tion of speech. Obligatory distortions second- know whether the nasal emission was consistent
ary to VPI include hypernasality, nasal or just occurred on one phoneme. In addition,
emission, and nasalized consonants. the clinician must be aware that when certain
 Speech Evaluation in Cleft Palate 245

sound, similar to a stethoscope. If hyponasality

or upper airway obstruction is suspected, the child
is asked to repeat syllables with nasal phonemes
(ie, ma, ma, ma) or prolong an /m/ while the exam-
iner listens through the straw. A muffled sound
suggests obstruction.

Ratings
There are many perceptual rating methods to
describe speech disorders associated with cleft
palate. These methods include categorical
judgments (eg, mild, moderate, severe); equal-
appearing interval scales; direct magnitude
estimation; paired comparison; and, more
recently, visual analog scaling.14 There are also
some standardized protocols for rating different
parameters of speech and velopharyngeal function
that can be used to compare speech outcomes in
Fig. 5. Mirror test of nasal emission. (From Kummer AW. intercenter studies. These protocols include the
Cleft Palate & Craniofacial Anomalies, 3E. Ó 2014 Cleft Audit Protocol for Speech-Augmented
Delmar Learning, a part of Cengage Learning, Inc. Re-
(CAPS-A)16,17 and the Universal Parameters.18
produced by permission.)
Speech parameters that are typically rated include
hypernasality, hyponasality, audible nasal air emis-
compensatory productions (eg, nasal fricatives) sion and/or nasal turbulence, consonant produc-
are present, mirror fogging may also result. tion errors, and voice. Although severity ratings
can be helpful in reporting and comparing intercen-
ter outcomes, ratings of severity do not usually
Straw
affect management decisions or the type of sur-
A straw is perhaps the best tool in assessing hy-
gery selected for correction.
pernasality and nasal emission. (It is also cheap,
always available, and disposable.) One end of
the straw is placed in the patient’s nostril and the Video Recordings
other end is placed near the examiner’s ear Because outcomes are usually determined based
(Fig. 6). The child is asked to repeat syllables or on auditory perception, it is important to obtain a
sentences with oral consonants only. Even slight high-quality digital video recording (or at least an
hypernasality or nasal emission can be heard audio recording) of a representative speech sam-
easily through the straw. The straw amplifies the ple as part of each assessment. These recordings
should be retained in the patient’s medical record.
They can also be used for pretreatment and post-
treatment comparisons, or for outcome studies
and intercenter comparisons.

INTRAORAL EVALUATION
Although the status of velopharyngeal function
cannot be determined through an intraoral exami-
nation, an oral examination has some importance
in the evaluation of VPI and abnormal resonance
in patients with a history of cleft palate.19 A very
thin velum is noteworthy because hypernasality
can be caused by transmission of sound through
thin tissue. During phonation, the position of the
Fig. 6. Straw test of hypernasality, nasal emission, velar dimple and uvula are examined. If the velar
and hyponasality. (From Kummer AW. Cleft Palate & dimple is skewed to one side or the uvula points
Craniofacial Anomalies, 3E. Ó 2014 Delmar Learning, to one side, the muscle function on the opposite
a part of Cengage Learning, Inc. Reproduced by side may be inadequate, causing a lateral velo-
permission.) pharyngeal gap. If the uvula is consistently
246 Kummer

deviated to the side of a large tonsil, this indicates converts this to a percentage value for the nasal-
that the tonsil is pushing against the posterior ance score. This score gives the examiner infor-
faucial pillar and probably extends into the mation about the relative percentage of nasality
oropharynx. Large tonsils should be noted (hypernasality and audible nasal emission) in
because they can cause pharyngeal cul-de-sac speech. Because nasometry measures both hy-
resonance and even affect articulation. In addition, pernasality and audible nasal emission, there is
dental occlusion is noted because malocclusion not a good correlation between velopharyngeal
can have a significant effect on speech sound gap size and the nasalance score (because nasal
production. emission is more audible with a small opening
than a large opening). However, with the knowl-
INSTRUMENTAL EVALUATION OF edge of the speech characteristics, the speech
VELOPHARYNGEAL FUNCTION pathologist can use the nasalance results to
confirm clinical impressions, and to do presurgical
Instrumental procedures can provide valuable in- and postsurgical comparisons.
formation to augment the perceptual evaluation
results.20–22 There are 2 basic categories of instru- Speech Aerodynamics
mental procedures for evaluation of velopharyng-
Speech aerodynamics is a procedure to measure
eal function: those that give indirect but objective
the mechanical properties of airflow and air pres-
information (eg, nasometry and aerodynamic
sure during speech production (Fig. 8).20–22,24
instrumentation), and those that give direct but
The aerodynamic procedure involves the use of
subjective information (eg, videofluoroscopy and
oral and nasal catheters that are connected to
nasopharyngoscopy).
pressure transducers, and a flow tube that is con-
nected to a heated pneumotachograph. The trans-
Nasometry
ducers convert the detected air pressure or flow
Nasometry is a computer-based procedure used into electrical signals. The pneumotachograph
to measure the acoustic correlates of resonance determines the rate of airflow.
and audible nasal emission. As such, nasometry Aerodynamic instrumentation can be used by
provides indirect information regarding the func- the speech pathologist to provide objective docu-
tion of the velopharyngeal valve (Fig. 7).20–23 Dur- mentation of intraoral air pressure levels and the
ing production of the speech passage, the amount of nasal air emission. With these data,
Nasometer II (KayPENTAX, Montvale, NJ) cap- the examiner can calculate an estimate of velo-
tures data regarding acoustic energy from both pharyngeal orifice size during consonant-vowel
the nasal cavity and the oral cavity during speech production. Aerodynamic instrumentation can
in real time. It then calculates the average ratio of also provide evidence of airway obstruction
nasal/total (nasal plus oral) acoustic energy and through measurements of nasal airway resistance.

Fig. 7. Nasometry. The nasometer headset is in place. Fig. 8. Speech aerodynamics. The catheters and flow
The nasometer collects acoustic data from the oral tube in place for measurement of the aerodynamics
and nasal cavities during speech. (From Kummer during speech production. (From Kummer AW. Cleft
AW. Cleft Palate & Craniofacial Anomalies, 3E. Palate & Craniofacial Anomalies, 3E. Ó 2014 Delmar
Ó 2014 Delmar Learning, a part of Cengage Learning, Learning, a part of Cengage Learning, Inc. Repro-
Inc. Reproduced by permission.) duced by permission.)
 Speech Evaluation in Cleft Palate 247

Videofluoroscopic Speech Study opening, which is important in surgical planning.

Even small, pin-hole-sized openings can be seen
Once the diagnosis of VPI has been made by the
through nasopharyngoscopy, but are not visible
speech pathologist, a videofluoroscopic speech
through videofluoroscopy (Fig. 10). The effect of
study may be done to evaluate velopharyngeal
the adenoids (positive or negative) on velophar-
movement and identify the structural deficiencies
yngeal function can be directly visualized. The
in velopharyngeal closure. This information may
nasal surface of the velum can be examined for ev-
be useful for surgical planning.20–22,25
idence of an occult submucous cleft. In addition,
Because videofluoroscopy involves two-
nasopharyngoscopy is effective in the assessment
dimensional imaging, a speech study requires
of the results of surgery for VPI.
several views in order to see all aspects of the
In performing the nasopharyngoscopy proce-
velopharyngeal port (Fig. 9). These views typically
dure, it is important to observe the relative contri-
include a lateral (sagittal) view, an anteroposterior
butions of the velopharyngeal structures to
(AP) view, and a base view. The speech patholo-
closure because these vary among normal and
gist selects the speech sample, based on the
abnormal speakers. Distinct patterns of velophar-
results of the perceptual evaluation. The speech
yngeal closure can be identified, based on the
pathologist is involved in the interpretation of the
extent of movement of the velum and pharyngeal
results, based on knowledge of the speech char-
walls (Fig. 11).29,30 The most common pattern of
acteristics and the probable cause.
closure is the coronal pattern. In this case, closure
Nasopharyngoscopy is accomplished primarily by movement of the
velum, which closes against a broad area of the
Nasopharyngoscopy (also called nasendoscopy posterior pharyngeal wall. The lateral pharyngeal
or videonasendoscopy) allows direct observation walls close against the velum on both sides.
of the velopharyngeal port during speech.20–22,26 When viewed from above through nasopharyngo-
In many centers, nasopharyngoscopy is done in scopy, a coronal slit is noted during complete
addition to or instead of videofluoroscopy27 closure. The next most common pattern of
because nasopharyngoscopy has several advan- closure is the circular pattern. With this pattern,
tages compared with videofluoroscopy. The all the velopharyngeal structures contribute
bird’s-eye view, as seen through nasopharyngo- equally to closure so that this pattern resembles
scopy, has been found to provide more accurate a sphincter. From a nasopharyngoscopy view, a
information about the severity of VPI than video- small midline circle is seen with complete closure.
fluoroscopy.28 Nasopharyngoscopy is superior to The circular pattern is often associated with a
videofluoroscopy in finding the location of a velo- Passavant because the superior constrictor
pharyngeal gap and confirming the size of the

Fig. 9. Videofluoroscopy. Lateral view showing the

velum and posterior pharyngeal wall during speech.
In this case, the velum is normal in structure, Fig. 10. This nasopharyngoscopy view shows a small
but has poor movement. As a result, there is a large but symptomatic velopharyngeal opening on the
velopharyngeal gap caused by velopharyngeal (patient’s) left. It is important to ne aware of this
incompetence. (From Kummer AW. Cleft Palate & opening for surgical planning. (From Kummer AW.
Craniofacial Anomalies, 3E. Ó 2014 Delmar Learning, Cleft Palate & Craniofacial Anomalies, 3E. Ó 2014
a part of Cengage Learning, Inc. Reproduced by Delmar Learning, a part of Cengage Learning, Inc.
permission.) Reproduced by permission.)
248 Kummer

Fig. 11. Patterns of velopharyngeal closure as could be viewed through nasopharyngoscopy. (From Kummer AW.
Cleft Palate & Craniofacial Anomalies, 3E. Ó 2014 Delmar Learning, a part of Cengage Learning, Inc. Reproduced
by permission.)

muscles are particularly active with this pattern with complete closure when viewed through
and they can bulge forward to produce this shelf- nasopharyngoscopy.
like structure during phonation. The least common These natural variations in closure are important
pattern of closure is the sagittal pattern. With this to recognize and understand during the nasophar-
pattern, the lateral pharyngeal walls are primary yngoscopy procedure because the basic pattern
contributors to closure as they move medially of closure may have an impact on the type of sur-
to meet in midline behind the velum. The velum gical intervention that is ultimately recommended
has a less active role. A sagittal slit is noted for correction of VPI.31
 Speech Evaluation in Cleft Palate 249

Passing the scope to perform this examination is (ie, oronasal fistula, VPI, or velopharyngeal mis-
within the scope of practice for speech patholo- learning). Most importantly, the examiner must
gists. However, what is most important is that determine the type of VPI and the cause of the
the speech pathologist is at least present during speech characteristics because this information
the examination and takes part in the interpreta- forms the basis for determination of the appro-
tion of the results. As with videofluoroscopy, priate treatment modality (surgery, prosthetic de-
knowledge of the speech sample and speech vice, and/or speech therapy).
characteristics is essential in interpretation of the Both types of VPI (velopharyngeal insufficiency
results because a velopharyngeal opening during or incompetence) require physical management
speech does not necessarily indicate VPI. for correction.1 Physical management usually
involves surgery, but may include prosthetic man-
DIFFERENTIAL DIAGNOSIS agement if surgery is not an option. If surgical
correction of VPI is indicated, nasopharyngoscopy
Based on the speech characteristics, the exam- can be particularly helpful in finding the location of
iner can make a diagnosis of VPD, and can the velopharyngeal opening (although this may be
even predict the approximate size of the velo- most important in patients with noncleft VPI). In
pharyngeal opening (Table 1). The examiner contrast, if there is velopharyngeal mislearning,
must determine whether there are obligatory dis- this requires speech therapy only.
tortions and/or compensatory errors. Both can be It is common for a patient to show both
the result of VPI or even malocclusion, which is velopharyngeal insufficiency and velopharyngeal
also common in patients with cleft lip and/or mislearning. For example, children with velophar-
palate. In addition, the type and consistency of yngeal insufficiency (a structural disorder) often
nasal emission can help to determine causality develop compensatory productions (a form of
velopharyngeal mislearning). In these cases, surgi-
cal correction is required first in order to correct
the VPI and normalize the velopharyngeal function.
Table 1 After structural correction, speech therapy is
Prediction of velopharyngeal gap size based on
necessary to correct the faulty articulation produc-
perceptual features
tions in the pharynx that continue to result in char-
Perceptual Relative acteristics of nasality.
Characteristics Predict Gap Size The primary purpose of the speech pathology
evaluation is to make this diagnosis through a
Severe
perceptual and instrumental assessment. If surgi-
hypernasality
Inaudible nasal
cal correction is needed, the speech pathologist
emission can also assist in determining the type of surgery
Weak consonants that has the best chance of success for the
Short utterance patient, based on the size and location of the ve-
length lopharyngeal gap. If a prosthetic device is indi-
Compensatory cated, the speech pathologist can assist in
productions fitting the device for maximum benefit. In addition,
Moderate if speech therapy is needed, the evaluation results
hypernasality are used for development of an individualize treat-
Audible nasal ment plan and determination of specific therapy
emission strategies.
Slightly weak
consonants
May be INDICATIONS FOR SPEECH THERAPY
compensatory
productions There is a common misconception about the role
Mild
of speech therapy in the management of what is
hypernasality often termed “cleft palate speech”. Speech ther-
Audible nasal apy cannot change abnormal structure and there-
emission fore cannot correct hypernasality or nasal
Nasal rustle emission caused by VPI, even if there is only a
(turbulence) small gap.32 There are no exercises that can
From Kummer AW. Cleft Palate & Craniofacial Anomalies,
change abnormal structure. Therefore, VPI (both
3E. Ó 2014 Delmar Learning, a part of Cengage Learning, types) requires physical management (surgery, or
Inc. Reproduced by permission. a prosthetic device if surgery is not an option).
250 Kummer

In contrast, speech therapy can correct place- 4. Loney RW, Bloem TJ. Velopharyngeal dysfunction:
ment errors (abnormal function) that cause nasal recommendations for use of nomenclature. Cleft Pal-
emission or hypernasality, specifically the com- ate J 1987;24(4):334–5.
pensatory productions that persist after the 5. Folkins JW. Velopharyngeal nomenclature: incompe-
correction of VPI.28 Because compensatory pro- tence, inadequacy, insufficiency, and dysfunction.
ductions typically involve articulation production Cleft Palate J 1988;25(4):413–6.
somewhere in the pharynx (where there is airflow), 6. Kuehn DP, Henne LJ. Speech evaluation and treat-
they are produced with the velopharyngeal valve ment of patients with cleft palate. Am J Speech
open. As a result, the airflow is released through Lang Pathol 2003;12:103–9.
the nose and there is nasal emission. Correction 7. Kummer AW. Assessment of velopharyngeal func-
of the velopharyngeal valve through surgery does tion. In: Lossee JE, Kirschner RE, editors. Compre-
not change this placement so the nasal emission hensive cleft care. New York: McGraw-Hill; 2009.
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general, if there is VPI, it is important to correct 9. Kummer AW. Perceptual assessment of resonance
the structure as soon as possible. Once the struc- and velopharyngeal function. Semin Speech Lang
ture is corrected, speech therapy is effective in 2011;32(2):159–67.
correcting the articulation placement errors that 10. Kummer AW. Speech and resonance assessment.
remain. The evaluation data form a basis for the In: Kummer AW, editor. Cleft palate and craniofacial
development of an individualized treatment plan. anomalies: the effects on speech and resonance.
3rd edition. Clifton Park (NY): Cengage Learning;
SUMMARY 2014.
11. American Cleft Palate–Craniofacial Association
All children with a history of cleft palate should (ACPA). Parameters for evaluation and treatment of
undergo a speech evaluation around the age of patients with cleft lip/palate or other craniofacial
3 years in order to rule out VPI. Through the anomalies. Cleft Palate Craniofac J 2009;
perceptual evaluation, the speech pathologist is 30(Suppl):1–16.
able to determine whether there is VPI, and also 12. Kummer AW. Disorders of resonance and airflow
whether there are obligatory distortions and/or secondary to cleft palate and/or velopharyngeal
compensatory productions as a result. Instru- dysfunction. Semin Speech Lang 2011;32(2):
mental procedures can provide objective data 141–9.
for pretreatment and posttreatment comparisons. 13. Baylis AL, Munson B, Moller KT, et al. Perceptions of
Nasopharyngoscopy is helpful in identifying the audible nasal emission in speakers with cleft palate:
location of the opening for surgical planning. VPI a comparative study of listener judgments. Cleft Pal-
always requires surgical correction. Speech ther- ate Craniofac J 2011;48(4):399–411.
apy is often required after surgery to correct the 14. Kummer AW, Briggs M, Lee L. The relationship be-
compensatory productions that continue to cause tween the characteristics of speech and velophar-
nasality. yngeal gap size. Cleft Palate Craniofac J 2003;
40(6):590–6.
SUPPLEMENTARY DATA 15. Kempster B, Gerratt B, Verdolini Abbott K, et al.
Supplementary data related to this article can be Consensus auditory-perceptual evaluation of voice:
found online at http://dx.doi.org/10.1016/j.cps. development of a standardized clinical protocol.
2013.12.004. Am J Speech Lang Pathol 2009;18:124–32.
16. John A, Sell D, Sweeney T, et al. The cleft audit
protocol for speech-augmented: a validated and
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