Download Cleft CEN Study Day – Nov 2015

Cleft CEN Study Day – Nov 2015
Case Study –
Prosthetic treatment for fistula
Ali Birch – SLT
(South Thames Cleft Service)
Why this case?
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Slightly unusual – adult case
Not a therapy case
Illustrated effective MDT working
Highlighted importance of SLT role in MDT
New to me!
Patient Background
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Female Adult patient – 31 years (From Columbia -in
the UK 2 years)
Repaired cleft of hard and soft palate
Original cleft surgeries- Columbia
Multiple surgeries
Persistent fistula in hard palate (post alveolus)
Referred to STCS by oral surgery due to concerns
around speech and nasal regurgitation
Felt speech was ‘holding her back’
Initial MDT Consult - Oral Exam
Surgical plan ++ time
Very scarred palate.
?Multiple surgeries
Appropriate for VPI?
Oral Exam
Initial MDT Consult
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D wanted fistula closed
Tricky surgery to close large fistula
May need multiple surgeries
V scarred palate
Effect on speech – pharyngoplasty visible
SLT ax to determine palate function and
effect o fistula
? Would D need palate investigations?
Initial Speech Assessment
GOSSPASS
Initial Speech Assessment
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GOSSPASS Assessment:
Resonance: Oral
Audible nasal emission detected on all
anterior sounds (/p/b/f/v/t/d/s/z/sh/ch/j/). No
emission on /k/ /g/)
No turbulence / grimace
Articulation – WNL no CSC
Initial speech ax
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Multiple fistulae in hard palate – did not extend into
soft palate
Soft palate function good – no features of VPD
Speech presentation – only emission accompanying
more anterior consonants. No emission on ‘k’ and ‘g’
Broad diagnostic test – likely to be fistula only
Role of SLT – planning treatment
Fistula v VPD
Nasal emission on
anterior sounds indicates air
escaping through
fistula and not
due to VPD.
What to do???
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No further investigation re palate function – just
required fistula closure.
Surgical plan complex. Surgeon wanted second
opinion re fistula closure.
Likely to take time… DM to give up smoking prior to
any surgery
Needed something until surgical plan in place
Cover fistula – initially this would sort speech and
nasal regurg?
Orthodontic help….
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My original idea – plate
Discussed with Orthodontist on team
Suggested 2 options:
1. Silicone bung
2.Vacuum formed retainer plate
Need to be a tight fit to reduce emission
Dental technician took impressions and
made bung and plate
Bung v Vacuum retainer plate
Fitting….
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Attended fit – bung was fine tuned!
D preferred bung only as was retentive and
felt plate was too bulky.
Plate only
Plate and bung
Bung only
Speech Assessment 2
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Assessed again with:
1. Bung and plate
2. Bung only
Very little difference perceptually between the
two.
Big improvement in reduction of nasal
audible emission!
Less inaudible nasal emission with both
Speech ax with bung
Gosspass
D’s reaction
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Very happy – felt she had regained her
confidence in speaking
Nasal regurgitation – much improved (still
occasional).
Bung + plate when eating – eliminated nasal
regurgitation
What next?
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Several surgical consults since fitting
Due FAMM flap in Nov 2015
If not closed completely – will make new
bung to fit any remaining fistula / fistulae
Thoughts
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Silicone bung – good long term option in complex
patients who may need to wait for surgery.
Tight fit and moulded to specific shape of fistula
Need to think about retention / choking risk.
Especially with younger children. Oldest 8/9?
Plate can help retention of bung
Cheap – easily replicated if lost
Well tolerated
If tight fit – helps to eliminate nasal emission.
Plate + bung appears better for helping nasal
regurg?
Thoughts….
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Plate + bung appears better for helping nasal
regurg?
Plate + bung appears better for helping nasal
regurgitation
SLT role central to management of this patient
Collaborative working with Orthodontist / surgeon/
dental technician
Easy fix compared to surgery.
Can use after surgery too if indicated
My first case –learning curve