Assessment of Persons with Cleft Lip and Palate: Assessment and treatment of clefts may require use of appropriate personal protective equipment. An SLP conducts a comprehensive speech and language assessment using both standardized and non-standardized measures.

Goals of Assessment

• Diagnosis of a speech, language, resonance, voice, and/or feeding and swallowing disorder
• Determination of the type, severity, and possible cause of the disorder
• Recommendation for therapy
• Identification of barriers to child and family participation in everyday situations
• Referral for surgical, prosthetic, or other medical or dental intervention
• Referral for genetic testing to rule out syndromes.

Assessment of persons with cleft lip and palate includes:

• Case History
• Orofacial Examination
• Audiologic Assessment
• Feeding and Swallowing Assessment
  • Non-Instrumental Assessment
  • Instrumental Assessment
• Subjective/Perceptual  Assessment of Speech Characteristics
  • Speech Samples
  • Speech Sound Production
  • Resonance
  • Nasal Airflow
  • Speech Intelligibility
  • Voice
• Objective/Instrumental Assessment of Phonatory, Resonatory and Articulatory Features
  • Phonatory
  • Resonatory
  • Articulatory
• Voice Handicap Index
• Subjective assessment of language and communication functions
  • Formal
  • Informal

Case History

• Family history of Cleft Lip and Palate
• Prenatal, Perinatal and Postnatal
• Developmental History
• Medical history (history of ear infections/fluid, history of ventilation tube placement, medical diagnoses, syndromic diagnosis and surgical history)
• Concerns regarding
  • Feeding Problem
  • Breathing or Snoring
  • Hearing Loss
• Family’s and other communication partners’ perception of speech intelligibility and resonance.
• Teacher’s perception of child’s speech and how it compares with the speech of peers in the classroom.
• History of speech and language therapy.
• Psychosocial concerns or issues.
• Family’s perspectives on their quality of life.
• Individual’s perspectives on his or her quality of life (see, e.g., Hall, Gibson, James, & Rodd, 2013).

Orofacial Examination

• Visually examine the child for structural differences/abnormalities (e.g., proportion and symmetry) of the craniofacial complex (including face, nose, eyes, ears, skull, and profile).
• Inquire about the presence of atypical nasal congestion.
• Assess oral cavity for
  • Symmetry and movement of oral structures (lips, jaw, tongue, velum)
  • Abnormalities of the tongue (e.g., Macroglossia, Akyloglossia, Asymmetry)
  • Presence and size of tonsillar tissue (large tonsils can play a role in airway and resonance problems)
  • Dentition and Occlusal status
  • Fistulae in the hard and/or soft palate (evaluate for size, location, and patency)
  • Evidence of prior palatal or pharyngeal surgery (scarring, placement of sphincter or pharyngeal flap)
• For individuals with no history of cleft palate, visually examine and palpate the soft palate—look for signs of possible submucous cleft palate, including
  • Bony notch at the junction of the hard and soft palate (the SLP should also palpate the palate to detect the presence of a notch that might be felt but not visualized)
  • Bluish line or translucent appearance down the midline of the palate (zona pellucida)
  • Midline furrow or v-shaped elevation during phonation
  • Bifid uvula
• Note the factors that might provide clues about etiology of VPD (e.g., symmetry of movement of soft palate during phonation).

Audiologic Assessment

• Otoscopic examination.
• Immittance testing to assess middle ear function.
• Pure-tone air and bone conduction to determine presence and type of hearing loss.
• Otoacoustic emissions testing to assess outer hair cell function.
• Speech detection threshold.
• Speech recognition (closed or open set, depending on age).

Feeding and Swallowing Assessment

Feeding assessment and expectations are based on the child’s age, neurologic and developmental status, and whether or not palate repair has been completed.

Non-Instrumental Assessment

• Eating,
• Drinking,
• Secretion management,
• Oral hygiene,
• Sensory status,
• The ability to accept food,
• The amount of diversity in their diet,
• Management of oral medications, and
• The caregiver’s behaviors while feeding their child

Instrumental Assessment

• The Videofluoroscopic Swallowing Study (VFSS), also known as the Modified Barium Swallow Study, is a radiographic procedure that provides a direct, dynamic view of oral, pharyngeal, and upper esophageal function (Logemann, 1986).
• Flexible Endoscopic Evaluation of Swallowing (FEES), sometimes also called fiber-optic endoscopic evaluation of swallowing, is a portable procedure that may be completed in outpatient clinic space or at bedside by passing an endoscope transnasally (Langmore et al., 1988).

Subjective/Perceptual  Assessment of Speech Characteristics

Speech Samples

• Formal Articulation Tests: There are several formal articulation tests that can be used for assessment of speech production. Although a formal articulation test with single words is a popular method to assess speech sound accuracy, there are many disadvantages to the use of a single word test.
• Single Sounds: If the child has limited connected speech or the examiner wants to isolate specific phonemes for assessment, the child should be asked to repeat single sounds or single syllables. Vowels, voiced continuants (for example, /v/ and /z/), and voiceless consonants can be produced in isolation. Voiced plosives and the voiced affricate (e.g., /bɑ, bi, dɑ, di, gɑ, gi, ʤɑ, ʤi/) can be produced only with a vowel.
• Syllable Repetition: In the syllable repetition test, the child is asked to produce syllables repetitively to assess each speech sound individually (i.e., /pɑ, pɑ, pɑ, pɑ, pɑ, pɑ, pɑ/).
• Sentence Repetition: To test speech and resonance in connected speech (and to also obtain some clues regarding expressive language), the examiner should have a battery of sentences for the child to repeat. (for example: /p/ – Popeye plays in the pool; /b/ –  Buy baby a bib; /m/ – My mommy made lemonade.)

Speech Sound Production

• Obligatory articulation errors: Those that are physically based/due to VPD or dental/occlusal differences
• Compensatory articulation errors: Including backed/retracted oral productions and learned nasal fricative patterns
• Developmental articulation errors and phonological errors.

Resonance

• Hypernasality: Excessive nasal resonance enhancement on vowels, glides, liquids, and, in severe cases, voiced oral consonants
• Hyponasality: Too little or absent resonance enhancement on nasal consonants and adjacent vowels, especially /i/ and /u/.
• Mixed Resonance: Elements of both hypernasality and hyponasality.
• Cul de sac resonance: A variation of hyponasality. Sound resonates in the nasal, oral, or pharyngeal cavity but is “trapped” by some obstruction.
  • Nasals (/m/, /n/, and “ng”) and nasalized sounds are “muffled” (due to anterior nasal obstruction).
  • Speech seems “mumbled” (e.g., due to small oral cavity).
  • Speech is described as “potato-in-the-mouth” (e.g., due to enlarged tonsils).

Nasal Airflow

• Visual Procedures
  • Hold a mirror under nares to detect nasal air emission—look for fogging during production of phrases containing oral pressure consonants and no nasal consonants (e.g., “Pick a puppy”).
  • Look for nasal grimace during speech that might coincide with nasal air emission.
• Tactile Procedures
  • Feel the sides of the nose for vibration that may accompany perceived hypernasality.
• Auditory Procedures
  • Alternately pinch and then release pressure on the nose (cul-de-sac test) while the child produces the same speech segment; listen for a resonance and/or pressure shift when nostrils are closed; VP valve dysfunction is signaled by cul-de-sac resonance and improved oral pressure with nose pinched.
  • Place one end of a straw or listening tube at nostril entrance and the other end to the examiner’s ear during production of oral consonants; listen for sound/airflow exiting the nostril.

Speech Intelligibility

• Intelligibility refers to understandability of speech.
• lack of speech intelligibility can negatively affect children’s overall communication effectiveness.
• Children with repaired cleft lip and/or cleft palate (CL/P) may experience poor speech intelligibility.
• There are several formal rating scales and tests are available, that can be used for assessment of speech Intelligibility.

Voice

• As part of the evaluation, therefore, the examiner should listen for characteristics of dysphonia, including
  hoarseness, breathiness, roughness, strain, glottal fry, hard glottal attack, inappropriate pitch level, restricted pitch range, diplophonia, and inappropriate loudness (Kummer & Marsh, 1998).
• These auditory perceptual aspects of vocal quality can be rated using the Consensus Auditory-Perceptual Evaluation of Voice (CAPE-V), which is a standardized protocol developed in 2002 as a result of a consensus meeting of voice specialists (Kempster, Gerratt, Verdolini Abbott, Barkmeier-Kraemer, & Hillman, 2009; Stemple, Glaze, & Gerdeman, 1995; Wilson, 1987).

Objective/Instrumental Assessment of Phonatory, Resonatory and Articulatory Features

Phonatory

• Acoustic Assessment: Objective measures of vocal function related to vocal loudness, pitch, and quality (Patel et al., 2018). In acoustic assessment we assess the Fundamental frequency, Vocal Intensity, Jitter, Shimmer, HNR, SNR etc.
• Aerodynaminc Assessment: This helps us assess the relationship between your airflow, air pressure, and the acoustic sound of your voice.

Resonatory

• Direct Observation via Imaging Studies
  • Multiview videofluoroscopy — provides real-time x-ray video image of velopharyngeal function during speech from a variety of angles.
  • Nasopharyngoscopy — provides detailed video of the velopharynx during speech from above the velopharynx.
  • Lateral cephalogram — provides a static x-ray of the palate at rest and during phonation of /i/, / u/ or sustained oral /s/
• Indirect Measures
  • Nasometry — measures nasalance, a ratio of acoustic energy from speaker’s oral and nasal cavities; nasalance is reported to have a modest correlation with listener ratings of resonance.
  • Pressure-flow studies — measure oral and nasal pressure and nasal airflow; allow for indirect computation of VP orifice size during consonant production.

Articulatory

• Electropalatography (EPG): It is a technique used to monitor contacts between the tongue and hard palate, particularly during articulation and speech
• Electromangnetic articulography (EMA): EMA (or EMMA, Electromagnetic Midsagittal Articulography) refers to kinematic tracking systems that use low field-strength electromagnetic fields to measure the movement of the tongue, lips, jaw, and velum.
• Electromyography: Electromyography (EMG) is a diagnostic procedure to assess the health of muscles and the nerve cells that control them (motor neurons).

Voice Handicap Index

• Voice Handicap Index (VHI) (Jacobson and colleagues, 2007) is the one used most commonly in clinical practice for self rating the voice.
• VHI consist three subscales Emotional, Functional and Physical. All subscale consist 10 questions.
• In VHI, patient self reported all questions using Likert Scale 0-never, 1-almost never, 2-sometimes, 3-almost always, and 4-always.

Subjective assessment of language and communication functions

• This can be done through screenings at the time of the yearly visits to the cleft palate/craniofacial team.
• If language problems are suspected from the screening or the parents express concerns about their child’s language development, a comprehensive language evaluation is warranted.
• A comprehensive language evaluation should routinely be done for children who have additional risk factors for language disorders (i.e., hearing loss, developmental delay, or neurological problems).

Formal

• Tests for children under the age of 3 include the
  • Receptive-Expressive Emergent Language Test (REEL-3), 3rd edition (Bzoch, League, & Brown, 2003)
  • The Early Language Milestone (ELM) Scale-2, 2nd edition (Coplan, 1993)
  • The Rossetti Infant-Toddler Language Scale (Rossetti, 2006).
• For children between the ages of 2 and 6,
  • The Fluharty-2 Preschool Speech and Language Screening Test, 2nd edition (Fluharty, 2000), can be used to screen both articulation and language development.
• Other preschool language tests include the
  • Clinical Evaluation of Language Fundamentals® Preschool, 5th edition (CELF-P®-5) (Semel, Wiig, & Secord, 2013)
  • The Preschool Language Scales, 5th edition (PLS™-5) (Zimmerman, Steiner, & Pond, 2011).

Informal

An informal language screening assessment can be done by these means:

• Observe play behaviors and the type and complexity of gestures and spontaneous utterances.
• Have interesting toys available and observe spontaneous vocalizations and utterances.
• Listen to the child’s spontaneous speech while he is talking to the parent.
• Ask the child to point to certain objects or follow certain commands.
• Ask simple either/or questions to get the child talking.
• Once the child is talking, ask questions that do not require a yes/no answer. In particular, ask for descriptions or explanations.
• Have the child repeat sentences, such as those listed in the articulation screening test. Have the child repeat sentences of increasing complexity. Even in repeating, the child will usually revert to his own form of syntax and morphology, which gives an indication of expressive language abilities.

References:

⇒ Cleft Palate and Craniofacial Conditions A Comprehensive Guide to Clinical Management –  Ann W. Kummer, PhD, CCC-SLP, FASHA (Book)
⇒ Cleft Lip and Palate – ASHA
⇒ Comprehensive Assessment for Cleft Lip and Palate – ASHA

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Assessment of Persons with Cleft Lip and Palate