AUTHORS

Corresponding Author

1) MS. ARPITA CHATTERJEE SHAHI

AUDIOLOGIST AND SPEECH LANGUAGE PATHOLOGIST

ALI YAVAR JUNG NATIONAL INSTITUTE FOR THE HEARING HANDICAPPED

EASTERN REGIONAL CENTER

B.T. ROAD, NIOH CAMPUS

BONHOOGHLY,

KOLKATA-700090., arpizee@yahoo.co.in, 8820688172

2) MR.INDRANIL CHATTERJEE

LECTURER

ALI YAVAR JUNG NATIONAL INSTITUTE FOR THE HEARING HANDICAPPED

EASTERN REGIONAL CENTER

B.T. ROAD, NIOH CAMPUS

BONHOOGHLY,

KOLKATA-700090.

inchat@gmail.com

“CLEFT SPEECH” A TELLTALE SIGN OF OCCULT SUBMUCOUS CLEFT: A Case

Study

ABSTRACT

The following article presents a case study of a child diagnosed with Occult Submucous cleft

palate. Submucous cleft palate is challenging to diagnose owing to the imperceptible presence of

this deformity. The present case report shares this challenging diagnosis and management. This

case study is interesting to note how perceptual assessment of speech may help in diagnosis and

management. The aim of the study is to explore the theoretical bases of submucous cleft palate

and its associated speech defects. The objective of the study is to determine the association of

speech and language impairment in submucous cleft palate in global perspective. A

comprehensive management of communication disorder in submucous cleft palate has been

given.

KEYWORDS: Occult, Submucous, cleft, communication.

INTRODUCTION

Submucous cleft palate, the cleft of the muscles and/or bone for the roof of the mouth is covered

by a mucous membrane, making it difficult to see the presence of the cleft when looking into the

mouth.7Some children shows signs of a submucous cleft palate (e.g., bifid uvula, midline groove

of the hard palate, or nasal sounding speech), while others may show no signs. Therefore, the

treatment of submucous cleft palate is quite variable.6,11

A submucous cleft is caused by several factors. In most cases, there is a combination of genetics

(inheritance) and environmental factors during the first few weeks of pregnancy.8 Submucous

cleft can occur as part of a genetic syndrome that causes other congenital anomalies. The most

common syndromes associated with submucous cleft are Stickler’s syndrome and

velocardiofacial syndrome (also called 22q.11 deletion syndrome).15

A submucous cleft palate is a relatively rare variant of the congenital malformation cleft palate

The estimated incidence of submucous cleft is 1 in 1200 to 2000 live births.13 According to two

studies done on the populations of normal primary school children for submucous cleft palate,

the incidences were- 1:1200 (0.08%) 20 and 1:6000 (0.02%).4,20

CLEFT PALATE AND ITS EFFECTS-

Children with submucous cleft palate face a variety of challenges, depending on the type and

severity of the cleft.18One of the most immediate concerns after birth is feeding. While most

babies with cleft lip can breast-feed, a cleft palate may make sucking difficult. In some cases, a

submucous cleft can cause difficulty with sucking. As a result, infants may take a longer time to

eat. They may also have fluid come through the nose occasionally. The biggest concern with

submucous cleft is its possible effect on speech .5 Most individuals with a submucous cleft have

normal speech. However, a submucous cleft can cause velopharyngeal insufficiency (VPI). VPI

is a condition where the defect in the velum (soft palate)3,10 prevents it from closing against the

pharyngeal wall (back wall of the throat) while talking, this can cause hypernasality or nasal air

emission during speech.12,13,21

CLASSIFICATION

Submucous cleft is mainly divided into two categories which include the classic submucous cleft

palate and the occult submucous cleft palate. The classic submucous cleft palate have triad of

overt physical finding which includes bifid uvula and furrow along midline of soft palate with

attenuated midline raphe, short palate with midline muscle separation and a notch in posterior

margin of hard palate.4 The functional findings in classic submucous cleft palate are the

hypernasal speech and velopharyngeal insufficiency. The other type of submucous cleft is Occult

submucous cleft palate. In this type there is muscle malposition in the absence of overt physical

findings and hypernasal resonance during speech.4,14

METHODOLOGY:

Brief History

A very vibrant typically developing child, she had occasional nasal regurgitation which was

often ignored and believed to be accidental. Her mother often felt that her child’s voice is

different but never seek any help for the same. Until and unless the hypernasality became more

prominent as her vocabulary increased. She was taken to general physician where they found no

other complication except adenoids. Accidently one day an otolaryngologist heard her voice and

suggested further radiological assessment. Finally at 2yrs and 2months of age she was diagnosed

to have submucous cleft palate which extending from hard palate upto uvula. The surgical

treatment was done at the age of 2 year 3 months of age. Palatoplasty surgery was done by Veau-

Wardil-Kilner (V-W-K) technique with Intravellar Veloplasty.7 Post surgery the child was

referred for speech and language therapy.

Speech and Language evaluation

The assessment started with a detailed case history session which showed no significant pre-natal

and peri-natal history, and was identified to have submucous cleft at 2 years 2 month of age. The

motor and speech and language development was age appropriate as reported. The oral

peripheral mechanism examination showed lips to be normal in appearance and function

(puckering, retraction, and seal). The appearance and functioning of tongue was normal

(Protrusion, Lateral movement, Elevation, Retroflexion was adequately present) teeth and

mandible was normal in appearance and function. Hard palate examination revealed repaired

cleft; length of the palate was short, width was normal, and ability to degluttate was adequate.

Soft palate showed repaired cleft, movement during the production of /ah/ was sluggish, ability

to suck through straw was inadequate, ability to blow paper bits/candle balloon/soap bubbles was

feebly present. Gag Reflex was present and uvula was short in length. Hypernasality was present.

Facial symmetry was present. Modified Striped Y Elsahy classification showed region 9, 10 and

11 i.e., Hard palate posterior to incisive foramen and Soft palate repaired by surgery. Language

evaluation revealed age appropriate language skills.

Speech and language therapy –

The Speech and language programme was based upon the results of the assessments done. The

baseline was compensatory productions which included poor oral resonance with hypernasal

voice quality. PRAAT showed formation of antiformants in oral sound indicative of

hypernasality. Nasal flutter test revealed hypernasal voice. Universal parameters ratings for

reporting speech outcomes in cleft palate showed a rating of 3 indicative of severe hypernasality.

Nasal emission “s” mirror test showed presence of nasal emission. Universal parameters ratings

for reporting speech outcomes in cleft palate showed a rating of 3 indicative of severe nasal

emission. Misarticulation Bzoch error pattern articulation test showed; nasalized plosives,

nasalized vowels, pharyngeal plosives substituted for the velar plosives k/g, palatal-dorsal

productions (mid-dorsum palatal stops), /p/ (bilabial, unvoiced, stop-plosive) substituted with

/m/ (bilabial, voiced, stop-plosive, nasal) and /d/ (labiodental ,voiced, plosive ) substituted

with /t/.

Duration of session was 45 minutes, once in a week. Language used for stimulation was Hindi.

The Long Term Goal6 was to facilitate 50% reduction of glottal stops and 50% correct

production of stop consonants and to facilitate age appropriate resonance after 12 sessions of

therapy and the Duration of plan was 3 months (12 sessions).

The short term goals were to reduce hypernasality, nasal air emission. It further included

reduction of misarticulation by 50% reduction of glottal stop, facilitation of production of

phonemes /d/ (labiodental, voiced, stop-plosive) and /p/ (bilabial, unvoiced, stop-plosive),

facilitation of production of velar plosive /k/ and /g/ and to facilitate correct production of /ʃ/ and

to facilitate increase in the mean  length of utterance.

The principles which were followed  during therapy8,16,17 was not to use blowing exercises,

sucking exercises, velar exercises or oro-motor exercises since the problem is rarely muscle

weakness and these exercises do not work. Pinching of nose to try to improve velopharyngeal

function was avoided because closing the nose actually makes it impossible for the velum to go

up. The figure 1 below mentioned target sounds according to hierarchy was chosen.

Figure 1 : HIERARCHY OF TARGET SOUND SEQUENCE

HIERARCHY OF TARGET SOUND SEQUENCE 6

Break glottal pattern with h – front (lip) low pressure , nasal    (/w/, /m/)

Front (lip) high pressure      (/p/ , /b/) ,(/f/, /v/)

Front (tip-alveolar ) low pressure (/y/,/n/)

Front (tip-alveolar ) high pressure (/t/,/d/)

Front (tip-interdental ) /ɵ/

Front (tip-alveolar ) /s/ ,/z/

Middle ( tongue-tip-palatal) high pressure /ʃ /, / ʈʃ / , / j/

Back ( tongue dorsum to velum ) nasal /ɳ/

Back ( tongue dorsum to velum ) /g/,/ k/

Back ( tongue tip retroflex ) /r/

The first target behavior was hypernasality and short term goal was to encourage oral resonance

in order to reduce hypernasality. Yawning and open mouth approach19 was used. During the

activity a ‘listening tube’ was used with which the child was made to discriminate between oral

and nasal sounds. The child was made to put one end of the tube in the entrance of the nostril and

the other end near her ear. When nasality occurred it was very loud through the tube. The child

was asked to reduce or eliminate sound coming through the tube as she produced oral sounds and

words. Similarly one end of the listening tube was put in front of the child’s mouth and the other

end near the child’s ear. The child was asked to try to increase the oral pressure on the oral

sounds and hear it through the tube. The second activity was yawning, followed by a vowel /i /-

target consonant (flattens base of tongue and elevates soft palate).

The second target behaviour was Nasalized plosives, nasalized vowels. The short term goal was

to encourage oral resonance. Yawning, cul-de- sac techniques were used. The child was asked to

produce a big yawn, which pushes the back of the tongue down and the velum up. The child was

made aware of the stretch in the back of his mouth. During the activity the child was made to

articulate the nasalized sound (vowel, bilabial plosive or lingual-alveolar plosive, or /l/) with the

yawn, while feeling the stretch in the back of the mouth. Auditory feedback was given at the

same time using listening tube or the Oral nasal listener.

The third target behavior was nasal emission and the short term goal was to reduce nasal

emission. Visual feedback and cul-de-sac technique was used. Handmade SEE-SCAPE, shown

in Figure 2 was self developed. It is a device with a vertical tube and a light weight ball in it that

rises when air is blown into it through the nose from another flexible tube that the child put near

nose. The device is used to make the child realize about the air escaped through her nose while

speaking and she was encouraged to reduce or stop the movement of the ball in the tube by

delivering the air towards the oral cavity.

Figure 2: Indigenous See-Scape

The fourth target behavior was Glottal-stops production .The short term goal was 50% reduction

of glottal stop; the child was made to produce the voiceless plosive and then the vowel preceded

by a /h/. For example, “p...ha” for “pa” and “p...ho” for “po”. This keeps the vocal folds open

and prevent the glottal stop. Gradually the transition time decreased from the consonant to the

vowel until the syllable is produced without glottal stop. This activity was practiced from the

first day of the therapy.

The fifth target behavior was substitution of /p/ and /d/ phonemes with /m/ and / t/ and the short

term goal was to facilitate production of phonemes - /p/ (Bilabial, unvoiced, stop-plosive) and /d/

(labiodental, voiced, plosive). Phonetic placement method1 and Minimal pair approach1 was used

for /p/. The sound was modeled several times. Attention was drawn towards the lip closure,

building up pressure in the mouth, and air explosion as the sound is produced. The lips were

manually guided to the required articulatory posture. Minimal pair approach was used to

differentiate between /p/ and/m/.1 This activity was practiced from the first therapy session.

For /d/, the child was made to practise words with the phoneme /d/ like- (doll, didi, daal) and was

made to add voicing while saying /t/. This activity was practiced from the 3rd therapy session.

The sixth target behavior was Pharyngeal plosives substituted for the velar plosives k/g and the

short term goal was To Facilitate production of velar plosive /k/ and /g/ Phonetic placement

(Establishment of placement for velar plosives (/k/ and /g/) by starting with an /ng/ a spoon

upside down was used to hold the tip of the tongue down. Then the chin was firmly pressed with

thumb to push the tongue up. Once /ng/ placement was established, the child was then made to

drop the tongue. Work on the up and down movement of the back of the tongue was done to

replace the back and forth movement which occurs with the pharyngeal plosive. Once the child

produced the /k/, voicing was added for /g/.This activity was practiced from the 5th therapy

session.

The seventh target behavior was Palatal-Dorsal Productions (Mid-Dorsum Palatal Stops). The

short term goal was correct production of /s/. A straw was placed at the front of the child’s

closed incisors and was asked to produce a /s/ and was asked to listen to the air stream that goes

through the straw. The straw was moved to the side of the child’s dental arch during production

of the /s/, and the child was asked find the place where the air stream can be heard through the

straw. The child was asked to put the straw at the front of his closed incisors and produce a /t/

while keeping the teeth closed. The child was asked to push the air into the straw at the front of

the teeth and hear the air through the straw. After achieving this position, the child was asked

to prolong /s/ without using /t/. This activity was practiced from the 8th therapy session.

The eighth short term goal was to facilitate increase in mean length of utterance. Enhanced

Milieu Teaching was used. The child was motivated to practice language when there is

functional consequence. Verb cards and toys were used. Opportunities for functional language

were created by arranging the environment to facilitate requests. Prompts were given and new

words were modeled in response to requests. To encourage practice of new words, adequate

expansion, praise and access to requested objects were provided. Phonological recasting was

done for correcting child’s utterances. Environmental arrangement was provided like a

naturalistic environmental setting was created such as an object (toy or stickers) which the child

likes were placed at a place where she cannot reach but can see. Mand-model like prompt for a

communicative response was given. Real questions like “what do you want?”, “what will you do

with it?” were introduced. An instruction to verbalize preference or give information was given

like “do you want a toy?”`. An opportunity to indicate a choice was provided like “do you want

an eraser or sharpener? Time delay was monitored such as a time delay of 5 seconds was given

to the child for giving response and was also reinforced to initiate responses.

STATUS REPORT AFTER 12 SESSIONS

Universal Parameters Ratings for Reporting Speech Outcomes in Cleft Palate 8

The parameters showed slight decrease in Hypernasality from level 3 (severe) to level 2

(moderate) in both single words and sentences. Decreased nasal air emission from frequent nasal

air emission to intermittent in both single words and sentences is also noticed. There was

decrease in consonant production errors. Increase in overall intelligibility from level 3 (severe) to

level 2 (moderate) in both conversational speech and whole speech sample were rated.

BZOCH ERROR PATTERN ARTICULATION TEST2,9

Increased intelligibility of plosives and glides which were indistinct due to nasal emission.

Decrease in simple and gross substitutions mainly in the initial and in the final position was seen.

Table 1: Pre and post therapy articulation data after 12 sessions

PRE-THERAPY POST-THERAPY

Nasal emission test 10/10

Hypernasality test 10/10

Hyponasality Test 0/10

Phonation test /i/ 5 sec

Nasal emission test 7/10

Hypernasality test 7/10

Hyponasality Test 0/10

Phonation test /i/ 6 sec

CONCLUSION

Submucous cleft palate often gets unnoticed because of the lack of visibility of this deficit.

Hence the intervention gets delayed and prognosis is hindered. In such situation presence of cleft

speech may help in diagnosis and intervention early. The present case study is an example of the

same.

ACKNOWLEDGEMENT

We are thankful to the parents of this child for their generous contribution and dedication.

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