Treatment for an Adult With a Recently Repaired Cleft Palate
Marie Byrne, Ph.D. and Lee Anne Rawson, M.S.
The Cleft Palate Foundation has noted that significant improvement can
be achieved by adults with speech problems related to cleft palate. There
is, however, a paucity of research regarding the treatment of adults with
recently repaired cleft palate. As colleges and universities recruit
students from countries with less available medical resources, more
adults may be seen who have craniofacial disorders.
Purpose
The purpose of this case study is to describe the effects of treatment on
nasalance scores and speech intelligibility for an adult following primary
palatal repair.
Participant
The participant in this study was a 33 year old female doctoral student
from the Philippines who received cleft lip repair at 5 years of age and
primary palatal repair on May 17, 2007 at the age of 31 years. She did
not wear an obturator before the surgical closure of the palate.
Initial Evaluation
The subject was seen for an initial speech-language evaluation on
September 13, 2007. Results of the evaluation revealed that the client
presented with a severe articulation disorder characterized by
●Nasal emission on all high pressure
consonants
●Hypernasal resonance on vowels
●Glottal stop replacement for /k/ and /g/
●Dorsal palatal articulation with glottal stop
coarticulation
for /t/ and /d/
●Lateralization of fricatives /s/, /z/, “sh” and
“zh” and
affricates “ch” and “j”
During the participant’s initial speech assessment, nasalance scores for
repeated syllables and production of the Zoo passage ranged from 61.07
to 66.59. Nasal emission was present on high pressure consonant
sounds.
Oral mechanism examination revealed an anterior and lateral crossbite
with a class III mesioclusion and a removable tooth implant for the left
lateral incisor. Several molars were missing on both upper and lower
dental arches. Hearing was within normal limits for both ears.
Treatment
Semester 1 – FALL 2007
Goals of treatment for the first semester of treatment included
● Increasing mouth opening and slowing speech rate
● Establishing production of /k/ and /g/
● Establishing correct place of articulation and eliminating glottal stop
coarticulation of /t/ and /d/.
Treatment techniques included the use of visual feedback to improve tongue placement,
successive approximation from “ng” to “g” and tactile feedback to eliminate glottal stop
production. Although speech sound production improved during this time, the client
continued to demonstrate hypernasality and nasal emission.
Semester 2 – SPRING 2008
The treatment goals during the second semester of therapy (spring, 08) included
.
● Generalization of “k” and “g” to conversational speech and
● Establishing improved production of “s”, “z”, and “ch”
Treatment techniques included use of listening straws and the Oral & Nasal Listener
(Kummer, 2007) to improve oral air flow for “s”, “z” and “ch”. Although progress was
made, speech continued to be hypernasal and nasal emission continued to occur on
sibilant sounds.
The Assessment of Dysarthric Speech Speech (Yorkson, K. and Beukelman, D., 1984)
was used to monitor changes in the client’s speech intelligibility. At the beginning of the
second semester of therapy, this assessment was administered to assess the
intelligibility of connected speech. Three students in the speech language pathology
program served as naïve listeners and transcribed five to ten word tape recorded
sentences they heard the client produce. Mean intelligibility was 44.3%. At the end of
this semester, this assessment was re-administered and mean intelligibility increased to
74% as judged by three different naïve listeners.
The client was referred back to her surgeon in February, 2008 due to concerns about
continued velopharyngeal dysfunction. The consultation, which was completed in May,
2008, revealed that enlarged tonsils were interfering with velopharyngeal movement.
The plastic surgeon also noted the presence of some tethering of the palate that had
occurred following the primary repair. On September 24, 2008, the tonsils were removed
and a revision was performed to the original palatal repair.
FALL 2008 – RE-EVALUATION
Therapy was not provided during the fall semester of 2008. The client was
reassessed at the end of the semester approximately six weeks after surgery.
Reassessment indicated lower nasalance scores for syllables with low vowels,
but nasalace was essentially unchanged for the Zoo passage (mean nasalance
= 63). Intelligibility as assessed by the Assessment of Intelligibility of Dysarthric
Speech had increased to 87.7% as judged by three naïve listeners and 99%
judged by the student clinician. Results suggested improved intelligibility and
resonance resulted from the tonsillectomy and revision to the palatal repair.
SEMESTER 3 - SPRING 2009
Speech therapy was resumed in the spring, 2009 semester. Treatment goals for
that semester included
● Improving production of “s”, “z”, “ch” and “j” in connected
speech and
● Decreasing nasalance using the Nasometer II to provide
biofeedback.
A reference criterion of 25% nasalance was set for a treatment goal. At the end
of the semester, mean nasalance ratings for sentences were 36% for sentences
containing no nasal sounds and 40% for the Zoo passage. She was producing
acceptable productions of fricatives and affricates in conversation with greater
than 90% accuracy.
Follow-Up
Follow-up assessment on October 23, 2009 revealed naslalance scores to be
virtually unchanged from scores at the time of discharge from treatment (Mean =
41%). Mean intelligibility was 79% as judged by three naïve listeners
transcribing sentences from the Assessment of Intelligibility of Dysarthric
Speech. Errors in word stress associated with English as a second language
were associated with some of the problems in word identification.
Conclusions
The results of this study reinforce the concept that treatment gains are possible
for adults who are motivated to improve their speech production. Although the
client continued to demonstrate hypernasality and occasional nasal emission
associated with high pressure consonants, substantial improvement was seen in
speech intelligibility. These gains were maintained six months after therapy
ended.