Download Oral peripheral examination for cleft palate/velopharyngeal

Oral peripheral examination for cleft palate/velopharyngeal dysfunction
Cecyle Carson, Ph.D. & Alejandro Brice, Ph.D.
University of Central Florida
University of South Florida, St. Petersburg
Abstract:
An oral peripheral examination protocol will be presented specifically for those who have
cleft lip and/or palate or velopharyngeal dysfunction (VPD). The protocol differs from
common oral peripheral exams in that it has the clinician observe specific structural
dysmorphologies and other issues associated with overt and submucous clefts. Examples
include detailed observation of the velum and posterior pharyngeal wall, as well as
questions regarding nasal regurgitation and upcoming dental/orthodontic plans.
Summary:
Clefts of the lip and/or palate occur in approximately 1 in 750 newborns, making
this deformity the fourth most common birth defect, and first most common facial birth
defect. Children born with clefts of the palate are susceptible to specific types of speech
and resonance problems associated with overt or covert clefts and/or VPD, including
hypernasality, nasal emission on or weak production of pressure consonants,
compensatory articulation errors, and articulation errors related to dental, occlusal, or
VPD issues; thus, specialized evaluation tasks are required.
Standardized oral mechanism examinations do not account for the special
structural and functional problems associated with those who have overt or covert (i.e.,
submucous or occult) clefts. Suggestions on assessing the oral mechanism in this
population are available via articles (e.g., Dworkin, Marunik, & Krouse, 2004; Kummer
& Lee, 1996) or books (e.g., Peterson-Falzone, Trost-Caramone, Karnell, & HardinJones, 2006). An oral examination protocol is needed that is specific for this population,
especially since a primary purpose of the exam is to provide an initial impression of
velopharyngeal functioning.
The oral peripheral exam protocol developed by the authors follows.
Oral Peripheral Examination Protocol
ORAL STRUCTURES
1.
LIPS
Unremarkable
Short Upper Lip
Tight Upper Lip
Unremarkable
Missing
Anterior malalignment
Lateral malalignment
Ectopic
Diastema
Comments:
2.
TEETH
Comments:
3. OCCLUSION
Unremarkable
Open bite
Overbite/closed bite
Collapsed alveolar arch(es) Anterior Cross Bite/Underbite
3a. Class of occlusion
Class I
Class II
Class III
Comments:
4. Hard PALATE
Unremarkable
High Arch
Prominent Ridges
Comments:
Prolong “ah” loudly. Then say “ah” “ah” “ah” “ah” or “ha” “ha” “ha”
5. Soft PALATE/VELUM
Unremarkable
Short
Asymmetric Elevation
Limited Elevation
Blue Line midline1
Notch/V-shape at posterior portion of hard palate1
Comments:
6. UVULA
Bifid1
Unremarkable
Absent/hypoplastic
Comments:
7. POST PHARYNGEAL WALL
Unremarkable
No or Minimal Lateral Wall Movement
Appears Too Deep
Enlarged Palatine Tonsils
Passavant’s Ridge
Comments:
8. FISTULA(s)
Absent
8a. FISTULA(s) LOCATION
Present
Alveolar Ridge2
Hard Palate3
Is the fistula size >4.5 mm? [Must be larger than this to have effect on velar movement]
Comments:
Soft Palate
Yes
No
9. SECONDARY PROCEDURE
None
Pharyngeal Flap
Sphincter Pharyngoplasty
Other
Comments:
10.
ORTHODONTICS/PROSTHODONTICS
None
Expander
Ortho Bands (braces)
Obturator
10 a. What are orthodontic plans?
10b. If present, does prosthetic affect speech?
Yes
No
Comments:
11.
HEARING
Otitus Media in past year?
1-3 bouts
4-6
PE tubes?
Present
None
>6
Comments:
12. Present FEEDING ISSUES
Yes
No
Yes
No
Comments:
13. NASAL REGURGITATION
Comments:
Notes:
1= signs of a submucous cleft; not all have to be present for a diagnosis of submucous cleft
2= sounds that could be affected by the fistula are anterior anterior pressure consonants /p,b,t,d,f,v,s,z/
3 = sounds that could be affected by the fistula are posterior pressure consonants /k,g/
Note: Factors not visible that can affect VP closure are: enlarged tonsils, pharyngeal web, deficiency of muscle
mass on nasal surface of velum (absent musculus uvulae), abnormal direction of pull of velar muscles, and
inadequate movement of pharyngeal wall for closure.
Dworkin, J.P., Marunick, M.T., & Krouse, J.H. (2004). Velopharyngeal dysfunction:
Speech characteristic, variable etiologies, evaluation techniques, and differential
treatment. Language, Speech, and Hearing Services in Schools, 35, 333-352.
Kummer, A.W., & Lee, L. (1996). Evaluation and treatment of resonance disorders.
Language, Speech, and Hearing Services in Schools, 27, 271-281.
Peterson-Falzone, S.J., Trost-Cardamone, J.E., Karnell, M.P., & Hardin-Jones, M.A.
(2006). The clinician’s guide to treating cleft palate speech. St. Louis, MO:
Mosby.