Chapter 14: Cleft Lips and Palates

Cleft lip is sometimes referred to as

"harelip", a term now considered inaccurate and insensitive - this term originated in the 16th century when a French doctor referred to a patient with a cleft as having the "lip of a hare [rabbit]", which was later shortened in English to "harelip".

SUBMUCOUS CLEFT

(sometimes referred to as an occult [hidden] cleft) A defect in the hard palate in the absence of an actual opening into the nasal cavity or a defect in the muscles of the soft palate that cannot be seen through the mucosal tissue but may cause disunity of the velar muscles, resulting in velopharyngeal incompetence and hypernasality.

Speech Aerodynamics

- is included in a complete assessment of velopharyngeal function - During production of oral pressure consonants, the velopharyngeal mechanism must separate the oral and nasal cavities - Conversely, during production of nasal consonants, the velopharyngeal mechanism must allow some degree of oral-nasal coupling - Air pressure during consonant production requires moving an airstream (e.g., fricative /s/) or a nonmoving air volume (e.g., stop-plosive /p/).

The more severe the cleft, the more likely the following behaviors will occur:

- parents perceive their infant as irritable and having less pleasing personality characteristics - mothers delay in touching their baby - and mothers are less interactive (less playful, less responsive, and less facial expressive) with their baby

The latest worldwide data (20 countries) from the World Health Organization reveal that the overall prevalence of cleft lip and/or cleft palate is approxmately

1 in 1000 births (9.92 per 10,000)

A cleft is a feature in more than

300 genetic syndromes (e.g., Apert syndrome, Crouzon syndrome, Pfeiffer syndrome, Pierre Robin sequence, Rett syndrome, Stickler syndrome, Teacher Collins syndrome, and velocardiofacial syndrome)

INTRAORAL AIR PRESSURE

A buildup of air pressure in the oral cavity that provides the force for the production of oral consonants, particularly plosives, fricatives, and affricates.

The Nasometer

A computer-assisted instrument that measures the relative amount of oral-nasal acoustic energy in an individuals speech - provides an easy, visual, noninvasive method for obtaining objective data about speech resonance and velopharyngeal function

VELOPHARYNGEAL DYSFUNCTION (VPD)

A condition where the velopharyngeal valve does not close consistently and/or completely during the production of oral sounds. - is a general term that may be used when etiology is not certain or is not specified, and can refer to either velopharyngeal incompetence or velopharyngeal insufficiency.

PALATAL (ORONASAL) FISTULA

A congenital abnormal small hole or passageway in the hard palate into the nasal cavity that allows intraoral air pressure and some sounds to enter the nasal cavity that can cause nasal emission and nasalization of oral sound. - also may occur as a postoperative complication of a cleft palate repair due to lack of adequate hearing. - can be surgically repaired

INTERDISCIPLINARY (MULTIDISCIPLINARY) TEAM

A group of professionals from various disciplines who work together to coordinate the care of a patient through collaboration, interaction, communication, and cooperation. - the parents are always essential members of the team

RULE OF 10s

A guidance for the appropriate time for a cleft lip repair, which says that the infant must be at least 10 weeks of age, weigh 10 pounds, and have a hemoglobin count of 10 gram before the lip repair

NASOPHARYNGOSCOPY

A minimally invasive procedure commonly used by SLPs for evaluation of velopharyngeal dysfunction that allows visual observation and analysis of the velopharyngeal mechanism during speech - equipment includes a flexible fiber-optic endoscope, the same that is used in laryngoscopy - the purpose is to view the nasal surface of the velum and all of the structures of the velopharyngeal valve during speech

PALATINE (FAUCIAL) TONSILS

A pair of almond-shaped masses of lymphoid tissue embedded in the lateral wall of the oral pharynx on either side between the palatalglossal and palatopharyngeal arches (faucial pillars). - Inflated tonsils (tonsillitis) may be seen as inflamed (red) or white lumps of tissue usually with a sore throat - chronic tonsillitis may require a tonsillectomy (surgical removal of the tonsils)

PALATAL OBTURATOR

A prosthetic appliance that can be used to cover an open palatal defect, such as an unrepaired cleft palate or a fistula (small hole in the hard palate).

SPEECH BULB OBTURATOR

A prosthetic device that may be considered when the velum is too short to close completely against the posterior pharyngeal wall - it consists of a retaining appliance and a bulb (usually made of acrylic) that fills in the pharyngeal space to help achieve oral-nasal resonance balance during speech

VIDEOFLUOROSCOPY

A radiographic (X-ray) procedure used to examine deep structures of the body during movement (including the soft palate), with the images recorded on a disk - The procedure can be used to diagnose the cause of velopharyngeal dysfunction as a short velum versus poor velar movement - can help confirm the presence of the velopharyngeal opening and estimate it's size - can help determine the optimal surgical or prosthetic management for individuals

HYPERNASAL (HYPERNASAILTY)

A resonance disorder that occurs when oral consonants and vowels enter the nasal cavity because of clefts of the hard and soft palate or weakness of the soft palate, causing a person to sound like he is "talking through his nose."

ESTUCHIAN (AUDITORY) TUBE

A tube lined with mucous membrane tissue that joins the nasopharynx and the middle ear cavity - normally closed but opens during yawning, chewing, and swallowing to allow equalization of air pressure in the middle ear with atmospheric pressure - (named after Bartolomeo Eustachio, an Italian anatomist, 1534-1574)

NASAL (AIR) EMISSION

Abnormal flow of the airstream through the nose during the production of consonants that require the buildup of intraoral air pressure on certain consonants (e.g., /p/, /b/, /t/, /d/, /k/, /g/, /s/, /z/) and is caused by a cleft of the hard or soft palate or velopharyngeal dysfunction that results in distortion of speech. - the escaping air tends to reduce the oral air pressure and impede the proper production fo the consonant - secondary effects are the development of improper compensatory pronunciation habits, including using a very soft voice that uses less breath pressure

VELOPHARYNGEAL INSUFFICIENCY (VPI)

An anatomical or structural defect that prevents adequate velopharyngeal closure, including a short velum, and is the most common type of velopharyngeal dysfunction.

TERATOGEN

Any substance, agent, or process that interferes with prenatal development, causing the formation of one or more developmental abnormalities in a fetus.

PHARYNGEAL FRICATIVES

Compensatory articulation productions primarily for fricatives and affricates (e.g., /f/, /v/, /s/, /z/, [sh] and [ch] used by individuals with velopharyngeal incompetence - characterized by tongue retraction so that the base of the tongue approximates, but does not touch, the pharyngeal wall, which causes a friction sound as air pressure passes through the narrow opening.

GLOTTAL STOPS

Compensatory articulation productions primarily for plosive sounds (e.g., /p/, /b/, /t/, /d/) used by individuals with velopharyngeal incompetence, - characterized by the forceful adduction of the vocal folds and the buildup and release of air pressure under the glottis, resulting in a grunt-type sound

Otitis media results form malfunction of the

Eustachian (auditory) tubes that connect the nasopharynx to the middle ear

PROSTHETIC DEVICES (PROSTHESIS)

For cleft palate, a device usually made of acrylic and metal, designed to close a cleft in the hard palate or the velopharyngeal port of speech

Cleft lip and palate have been written about since

Hippocrates (400 B.C) mentioned cleft lip- though not cleft palate- in his writings.

VELOPHARYNGEAL INCOMPETENCE (VPI)

Neuromotor or physiological disorders that result in poor movement of the velopharyngeal structures.

ORTHOGNATHIC SURGERY

Surgery that involves the bones of the upper jaw (maxilla) and lower jaw (mandible)

The American Cleft Palate-Craniofacial Association (2016) has established basic standards for what constitutes a professional cleft palate or craniofacial team:

The minimum core professionals must include a surgeon, a speech-language pathologist, and an orthodontist, all of whom are qualified by virtue of their education, experience and credentials to provide craniofacial and cleft care.

HYPONASAL (HYPONASALITY, DENASAL/DANASAILITY)

The perceived sounds when there is complete blockage of the entrance to the nasal passages and the /m/, /n/, and (ng) sounds are eliminated when this occurs, the nasal consonants sound more like/b/, /d/, and /g/. - refers to the reduction in nasal resonance during speech that is caused by partial blockage (occlusion) in the nasopharynx or the posterior entrance to the nasal passages, as might occur when the adenoids (masses of lymphoid tissue on the posterior pharyngeal wall of the nasopharynx) are enlarged - especially affects the nasal consonants, distorting them

The most reliable assessment results require

a combination of noninstrumental, perceptual, and objective measures

A cleft lip that extends through the alveolar ridge results in

a division of the orbicularis oris muscle in unilateral clefts (one side), with more severe clefts occurring with bilateral clefts (both sides).

Children with clefts generally have

a significantly lower self-concept than their non-cleft peers - they generally perceive themselves as less social adept and more often sad and angry than children without clefts.

People without syndromes may have clefts, and their clefts may sometimes be the result of

a single mutant (abnormal) gene.

The assessment of resonance and velopharyngeal function begin with

a speech-language pathologist's perceptual evaluation to determine whether resonance is normal or abnormal

Clefting can

affect a infant's ability to suck and nurse.

How children look and sound when entering elementary school

affects how they perceive themselves and their social interactions. - A child's facial appearance is strongly correlated with attractiveness and social acceptance

The See-Scape

allows the clinician to view air movement (nasal emission) by observing a Styrofoam stopper in a glass tube while the client produces oral pressure consonants with a "nasal olive" placed against the nostril - The clinician can place her finger lightly on the child's nasal alae ("wings" of the nose) when he produces the sustained sibilant, /s/ or /z/. - If vibration is detected, it indicates hypernasality and nasal emission

The newborn may have older brothers and sisters, who

also will be reacting to the baby's appearance during this time - the newborn's condition has psychosocial impacts on the siblings, and it is important to incorporate support for the siblings as well as the parents

Various other team members may be involved at different stages of care of the infant/child, including

an audiologist, geneticist, neurosurgeon, nurse, nutritionist, ophthalmologists, oral surgeon, prosthodontist, psychologist, radiologist, social worker, and speech-language pathologist.

Difficulty in feeding or inability to feed efficiently is

an immediate problem for infants born with cleft lip, cleft palate, or both.

Management of children with cleft lip and palate requires

an interdisciplinary (multidisciplinary) team approach in which the team members collaborate on and coordinate the care of the patient and family

In individuals with cleft palates, some articulation errors

appear to develop to compensate for velopharyngeal incompetence.

The primary speech-pathology concerns at the initial team evaluation of an infant with a cleft

are feeding and the development of the prerequisites for verbal communication - Nursing staff and the SLP help train parents on feeding techniques of the baby

The speech therapy techniques used with articulation disorders related to resonance disorders (compensatory production such as glottal stops and pharyngeal fricatives)

are similar to those used in basic articulation and phonology therapy.

If a cleft lip is not repaired in infancy (as in the case of many countries around the world)

articulation can be affected, whereby the child is not able to develop normal intraoral air pressure to produce pressure constant sounds such as plosives (e.g., /p/, /b/) , fricatives (e.g., /f/, /th/, /s/, /sh/) and affricates (e.g. /ch/)

Speech therapy can improve their

articulation or phonological development, general expressive language abilities, or a combination of these

Several methods may be used to assess velopharyngeal function, such as

assessment of the acoustic correlates of resonance, speech aerodynamics, nasopharyngoscopy, and videofluoroscopy

Infants and children with cleft palates are considered

at high risk for otitis media with effusion (middle ear infections) and associated conductive hearing loss

A small "air paddle" (about the shape of a table tennis [ping-pong] paddle) can

be cut from a piece of paper and placed underneath each nostril while the child is rapidly producing the sounds pa pa pa, ta ta ta, ka ka ka - If the paddle moves during the production of these sounds, it indicates there is nasal air emission

Because a cleft is a "chronic" problem, the parents reactions may

become chronic as well, and a social worker or psychologist may be needed to deal with the parents' feelings about having a child with a craniofacial anomaly

More severe yet are clefts through

both sides of the lip that extend to the floor of the nostrils = bilateral cleft lip

In addition, social, cultural, and religious attitudes toward birth defects affect

both societal willingness to provide medical treatment to individuals with all types of disabilities and individual willingness to seek treatment.

By age 4, the child has likely had

both the lip and the palate surgically repaired, if necessary, although there still may be significant velopharyngeal dysfunction, hypernasality, and nasal emission.

An incomplete cleft

can be as minor as a small notch in the lip tissue with no involvement of the alveolar ridge.

Feeding specialists (including speech-language pathologists trained in this area)

can help mothers find the best method of providing nutrition to their infants.

The best assessment procedures involve

careful listening for hypernasality and nasal emission

Maternal nutrition deficiencies have been implicated in

causing clefts and other malformations - In particular, inadequate folic acid in the maternal diet may affect embryonic and fetal development.

By the age of 3 or so, the child should undergo a language evaluation, because

children with a history of cleft or craniofacial anomalies are at risk for early language delays

During the dark ages of history and into the 17th century, superstition suggested that

children with cleft lips were born to women who, when pregnant, were frightened by the devil, who had assumed to have relations with the devil, and both she and the infant were put to death.

No single cause or etiological can explain the occurrence of

cleft lip, cleft palate, or both.

Cleft of the soft palate may occur, as well as

clefts of the hard and soft palates (referred to as complete cleft palate) , clefts of the alveolar ridge and hard and soft palates, or clefts of the lip, alveolar ridge, and hard and soft palates.

A variety of special bottles adn nipples are

commercially available to help with feeding problems

Conductive hearing loss are

common with clefts, so hearing screenings should be performed regularly. - Tympanometry measurements should be made when there is a suspected middle ear infection (otitis media).

Resonance disorders are

commonly seen in children with clefts of the hard and soft palates.

Hypernasality is easiest to perceive in

connected speech, and it often increases during faster rates of speech.

Physical appearance concerns are

consistently higher in adolescents with a history of clefts, particularly in girls

A considerable amount of time is devoted to

counseling the parents and teaching them about speech and language development and their stimulation

Cleft lip and palate can contribute to

dental anomalies.

These noninstrumental techniques include the mirror test to

detect nasal emission, in which a small mirror (e.g., a dental mirror) is placed under the nose to observe any fogging while the child produces intraoral air pressure (oral pressure consonants) sounds such as /p/, /b/, /t/, /d/, /k/, /g/, /s/, /z/; words such as badges, boat, cookie, and cupcake; and sentences such as "I like coca-cola"

Many plastic surgeons follow the rule of 10s to

determine an infant's readiness for lip repair

Culture and country of origin must be considered when

developing a complete profile of people with clefts.

Parental reactiosn to first seeing their baby's birth defect include

disbelief, shock, anger, guilt, depression, feelings of inadequacy, resentment, grief, frustration, anxiety, fear, and protectiveness - all common reaction to any serious physical defect of a newborn - these emotions are not just fleeting feelings

Adult with repaired clefts have a high rate of

dissatisfaction with their appearance, teeth, hearing, speech, and social life

Grandparents have their own reactions, but most

do the best they can to be supportive of the new parents and the other grandchildren

A number of studies have examined how

early elementary school-age children with craniofacial anomalies perceive themselves. - the children reported feeling more alienated, sadder, and more scared, angry, and upset than the normal-appearing control groups

In some developing countries, treatment for cleft lip and palate may be a relatively low priority because of

economic hardships, poor availability of treatment, and other factors,

New mothers must learn specialized feeding techniques to

ensure their infants with clefts receive sufficient nutrition for growth and health.

The team approach (which includes the family) is

essential in the successful management of children with clefts. - Speech and language therapy should continue as long as a child is making progress.

Pedontists (dentists who specialize in children) and orthodontists are

essential professionals on the cleft palate team.

An oral-peripheral examination is

essential to integrate all of the information about the cleft - Careful observation and notes should be made about the structure, symmetry, and function of the maxilla and mandible, lips, dentition, tongue, hard palate, soft palate, palatine (faucial) tonsils, and pharyngeal walls.

If the child is talking in short sentences and producing a variety of sounds, it may be possible t

evaluate resonance and velopharyngeal function in connected speech.

In most severe cases, the cleft may

extend on one side through what would have been the philtral ridge up to the floor of the nostril - unilateral complete cleft lip

In many cases, these factors influence

families' attitudes toward treatment and even the availability of treatment

Some of the myriad problems associated with cleft lip and palate include

feeding difficulties, middle ear infections, and dental anomolies

Consonants that require more intraoral air pressure will

force more air into the nasal cavity and increase the perception of hypernasality (e.g., plosives /p/ and /b/, fricatives /s/ and /z/, and affricates /sh/ and /ch/)

Among experienced SLPs there is often

good intrarater reliability for the perception of hypernasality, nasal emission, and speech intelligibility. -

They report significantly

greater dissatisfaction with their appearance, less success in school, and greater general unhappiness and anxiety compared to other children

Parent-infant attachment and bonding when a child has a cleft lip and/or palate

has been a concern for years

Studies have revealed that during speech development, young children with clefts

have a smaller phonetic repertoire and use restricted syllables and structures in the formation of their early words, although there is considerable variation among children - children may have articulation and phonological problems that are unrelated to the clefting

Children with various craniofacial anomalies may

have ear deformities, particularly when syndromes are involved.

To evaluate children for velopharyngeal dysfunction, Speech-language pathologists also

have several simple noninstrumental, low-tech, and "no-tech" techniques

The nose pinch test ilvolves

having the child prolong a vowel, first with the nostrils unoccluded and then with the nostrils occluded (pinched), and then produce a speech segment (e.g. "I like Coca-Cola") using the same procedure - If the child has good velopharyngeal competence, there should be no perceptible difference - If the child has velopharyngeal dysfunction, the sounds will be hypernasal with the nostril unoccluded and sound normal with the nostrils occluded.

The complexity of the surgery is determined by

he size of the cleft (incomplete versus complete) and whether the cleft is unilateral or bilateral

Parental involvement and even older siblings are

important for success of therapy - Family members should be encouraged to observe and participate in therapy to lean how to continue this practice in the home environment

Perceptual assessment should be performed and instrumental measures administered prior to any surgery designed to

improve speech or surgery that might affect the child's speech, such as orthognathic surgery for repositioning bones of the maxilla and mandible

If there is no abnormality, as judged by a perceptual evaluation, then

instrumental procedures become less important, if not unnecessary

In a cleft lip, the orbicularis oris muscle that forms the upper lip

is divided and misaligned as it curves upward with the cleft

In another form of the cleft, the mucosal tissue covering the hard palate

is intact but there is a small hole (palatal fistula) in the hard palate.

Velopharyngeal incompetence can affect speech and resonance in a variety of ways, but in particular

it can cause hypernasality and nasal air emission. - The speech intelligibility of many individuals with cleft palates is severely affected as well.

When a child has a cleft lip, cleft palate, or both,

it is reasonable to consider the possibility that a syndrome is involved - Likewise, when a child has a syndrome, it is wise to look closely for any type of clefting.

A variety of clefts can occur, some affect

just the lip, either unilaterally or bilaterally; others affect the hard palate and still others affect just the soft palate. - The most severe clefts occur when all three structures are involved.

The central (median) and side (lateral) portions of the upper lip fuse together by 8 weeks' gestation to form three segments of the lip

left side, middle (philtrum), and right side (the small philtral ridges are the fusion lines).

Various types of speech appliances may be used to

lift the soft palate to hold it in place close to or against the posterior wall (palatal lift), to cover an open defect in the hard palate (palatal obturator), or occlude the velopharyngeal port during speech (speech bulb obturator)

Some individuals have cosmetic surgeries for

lip revisions, nose revisions, or both. - it is not unusual for older children, adolescents, and even young adults to have cosmetic surgeries during their summer vacations from school - Although cosmetic surgery can make individuals look remarkably good, scar tissue may still be noticeable.

Severe clefts present significant oral feeding problems, resulting in

low volumes of oral intake, decreased nutrition, and poor weight gain - Adequate nutrition and weight gain are necessary before lip and palatal surgery can be performed.

Parents and teachers often need help to realize that

many children with clefts feel rejected and are rejected by their peers - Because of this, children with clefts may need special training and experiences in ways to positively handle teasing and ridiculing and to develop good social skills

Several studies have reported that adults with repaired clefts

marry later and less often than other adults - there are also more childless couple and fewer children per marriage, perhaps because of prospective parents; fear their own children will have clefts

Children with clefts have various problems with their bite as a result of

maxillary and mandibular misalignment.

The auricle (outer ear) as well as the middle ear and ossicles (three small bones in the middle ear)

may be abnormally formed.

The various problems associated with cleft lip and palate can have cascading effects on speech. For example,

middle ear problems and infections can negatively affect the development of speech sounds and phonetic repertoire that are the building blocks for words, sentences, and language.

One of the most common problems is

missing teeth

Primary palatal surgery performed before 12 months of age is

more likely to prevent compensatory articulation behavior such as the production of glottal stops

In addition to closing the hard and soft palates so that they form a barrier between the mouth and nasal passages, the surgeon

needs to repair the soft palate so that it functions dynamically (i.e. is able to move) for normal speech.

Many parents of babies with clefts have

never heard of or seen pictures of clefts (harelip is usually the term adults have heard) before their child's birth

The goal for the children who have had successful cleft palate repairs and have achieved functional velopharyngeal mechanism is

normal apseeh

This direction of fusion allows for

normal development of the anterior portions of the hard and soft portions of the hard and soft palates and only a minor defect of the uvula, resulting in a bifid uvula (divided uvula)

Functional hard and soft palates are necessary for

normal oral-nasal resonance balance (i.e. oral sounds are oral and nasal sounds are nasal).

Achieving a good result with palatal surgery is

often more difficult than achieving a good result with lip surgery - Palatal surgery is technically more challenging and has more potential complications

The term cleft palate speech is

often used to describe the typical consonant productions, abnormal nasal resonance, abnormal nasal airflow, altered laryngeal voice quality, and nasal or facial grimaces of children with clefts of the hard and/or soft palates.

By doing the initial cleft lip surgery between the second and third months of life,

physicians have more time to investigate other potential problems the infant may have, such as syndromes or medical complications - The infant will also have established a feeding technique that allows weight gain

A flexible straw can be used to detect velopharyngeal dysfunction by

placing the short end of the straw in the client's nostril and the long end of the best straw in the clinician's ear. - Ask the child to produce a vowel and then a speech segment and listen for hypernasaility and nasal emission

Children with clefts tend to have

poor receptive and expressive language skills, shorter mean length of utterance, reduced structural complexity, smaller vocabularies, and poor reading skills.

Most human traits are multifactorial, that is

probably several genes, possibly combined with environmental factors (e.g. maternal nutrition), determine the expression of traits such as height, hair color, and eye color, as well as intelligence and other cognitive traits. -The multifactorial model is widely accepted as an explanation of clefts without accompanying syndromes

When surgical correction of velopoharyngeal dysfunction is not an option or when surgical management and speech therapy have not been able to sufficiently improve oral-nasal balance,

prosthetic management may be used.

Resonance is said to be abnormal if the

quality or the intelligibility of speech is affected by inappropriate transmission of acoustic energy in the vocal tract (i.e., into the nasal passages)

Individuals with repaired clefts generally assume a

reasonable position in society and typically fall within the norms in terms of their educational levels, employment, psychosocial adjustment, and social integration.

Most children with cleft lips undergo some secondary surgery (revisions) in early child to

reduce scar tissue on the lip, improve the symmetry of the lip, and improve the symmetry and appearance of the nose

HYPERNASALITY

refers to an excessive and undesirable amount of perceived nasal cavity resonance during speech - it occurs when abnormal coupling of the oral cavity and nasal cavities results in distorted or nasal-sounding vowels and oral consonants (recall that only /m/, /n/ and /ng/ are nasal consonants)

Ideally, videopharyngeal incompetence has been surgically managed by this time and therapy focuses on

residual compensatory errors (glottal stops, pharyngeal fricatives ) and other articulation and language problems.

Other secondary surgeries may not be performed until there is no complete facial growth during the elementary school and adolescent years. For example,

secondary surgery to straighten the nasal septum (the fleshly partition between the nostrils) and improve the nasal airway may not be performed until the teen years

during the first 4 years of the child's life, the SLP

should conduct a yearly screening of the child's oral mechanism and speech and language skills to monitor their development

Clefts may be caused by

single genes, chromosomal disorders, or intrauterine environmental factors.

Although the hard and soft palates may appear intact,

some disunity of the muscles of the soft palate may be present that results in in velopharyngeal incompetence and hypernasality - however, some individuals do not have any noticeable speech problems and the submucous cleft may go undetected throughout life.

Children with clefts also have more

speech, language, and/or reading problems than other children, and these issues are potential indicators of psychological risk.

For centuries, clefts were considered to be caused by

syphilis, and it was not until 1556 that Pierre Franco recognized clefts of the lip and palate were congenital disorders,

Individuals with velopharyngeal incompetence are unable to build the necessary intraoral air pressure to produce stop sounds because

the air escapes into the nasal passageways, resulting in hypernasality and nasal (air) emission.

During the preschool years, children's self-image and feelings about themselves are influenced primarily by

the attitudes and behaviors of their parents

Most parents have no advance warning or opportunity to prepare for the birth of a child with a cleft;

the baby is born and the parents;' first awareness of the facial anomaly is when they are shown their new baby

Speech therapy by itself cannot manage hypernasality or nasal emission; instead,

the child will need further surgical management or a prosthetic device to remedy these issues

A cleft of any type is not painful to the infant because

the cleft is not a wound but rather a malformation; therefore, the tissues around the cleft are not tender or sore to touch.

A major cause of stress for many parents is

the cost of a cleft palate team, surgery, and the care needed for these children - Even though third-party payers may cover teh cost of much of a child's surgical management, dental work, and speech therapy, there are always many expenses that must come out of the pockets of the families

Clefts can severely affect

the development of many sounds.

Resonance disorders causes by velopharyngeal incompetence are

the hallmarks of cleft palate.

During the first trimester of pregnancy, the embryo is particularly vulnerable to

the influences of harmful agents or teratogens, including cigarettes and alcohol.

As children's interactions with the community expand during the school years,

the influences on self-image, socialization, school adjustment, and academic achievement becomes more complex

The more severe the cleft of the lip,

the more likely the alveolar ridge will be involved as well as the hard and soft palates

listener judgment by a qualified and experienced speech-language pathologist is

the most important test for velopharyngeal dysfunction

Improved overall articulation decreases

the perception of mild hypernasality

in general, the poorer the speech intelligibility,

the poorer the expressive language.

During the first 3 years of the child's life, language development is

the primary focus, rather than good intelligible speech, - the quantity of speech is more important than the quality of speech.

Resonance is

the quality of the voice that results from the vibrarion of sound in the pharynx, oral cavity, and nasal cavity

Most children with cleft palates will need

the services of a speech-language pathologist at some time in their lives

Numerous complicated dental anomalies, including missing teeth, rotated teeth, and misaligned teeth, require

the services of dentists and orthodontists.

The most important for waiting until this time to perform surgery is so that

the surgical team knows that the infant can survive the long period (usually 1 to 2 hours) under general anesthesia.

In the literature on cleft palate and velopharyngeal closure,

the terms velopharyngeal dysfunction, incompetence, and insufficiency are often used interchangeably.

When a bilateral cleft lip extends through the alveolar ridge

the tissue that would have formed the philtrum and alveolus is often a mass that protrudes and may cover the nostrils - in these cases, the nose is often involved and is wide, flat, and malformed.

Between the 8th and 12th weeks of gestation,

the two palatal shelves in the roof of the mouth fuse together, with the fusion occurring in an anterior to posterior direction - (you can feel the fusion line or "seam" by running your tongue tip over the roof of your mouth)

Among adults, an indicator of self-satisfaction and feelings of success in social interactions is

their dating and marrying partners

Adolescents view appearance as

their most important characteristic, ranking it above intelligence and humor

The incidence of clefts varies in racial groups, but in general

there are twice as many clefts in Asians as in Caucasians, and twice as many clefts in Caucasians as in blacks. - the causes of these variations in the incidence of cleft lip and palate among various racial groups have not been clearly determined

Also, many parents have had little experience with hospitals before the birth of their baby, and now

they must learn to navigate the complexities of the medical system as well as third-party payers - A knowledgeable and compassionate social worker can be most helpful to the parents at this time

The goals of the cleft lip surgery are

to achieve unity of the orbicularis oris muscle and normal lip configuration with cupid's bow.

The goal of physical (surgical) management and speech therapy in the preschool years is

to attain age-appropriate speech, or something close to it, before the child enters kindergarten

Speech-language pathologists who are member of cleft palate (craniofacial anomaly) teams are likely

to be involved in the initial team evaluation of an infant with a cleft soon after the birth

The goal of surgical closure of the palate is

to establish an intact division between the oral and nasal cavities, including a fully functioning velopharyngeal system.

Many school-age children with repaired cleft palates continue

to have speech problems, for which they are usually treated by school-based SLPs.

Indications that a submucous cleft may be present are the

triad of a bifid uvula, a bluish tint in the midline of the soft palate (the "blue line effect"), and hypernasality.

Both males and females with facial clefts, regardless of whether they have a facial disfigurement,

typically rate their quality of life as lower than that of their peers

Children with cleft palates are at risk for

various language delays and disordrs compared with children without clefts, particularly when their clefts are assoiciated with syndromes or other disordres

When this fusion does not proceed as expected, it may result in

various types of cleft lip and different degrees of severity

Even after surgical management of a cleft palate, many children are left with some

velopharyngeal dysfunction that can significantly affect speech intelligibility.

A cleft of the soft palate can cause

velopharyngeal insufficiency or incompetence that results in hypernasal speech

Clinicians must determine when

when it is appropriate to initiate therapy, when it is appropriate to refer clients for physical management, and when it is prudent to defer management

One or more teeth are often absent from clefts in the alveolar ridge, however

when teeth are present, they may be smaller than normal or malformed.

Speech and language problems are common among children with clefts, particularly

when the clefts are associated with syndromes (e.g., Teacher Collins syndrome and Pierre Robin sequence).

Speech therapy focusing on correct articulator placement may be initiated prior to secondary surgical procedures,

which often takes place between 3 and 5 years of age.

For many of these children, the course of speech and language therapy

will be long and complex