We are pleased to announce that our chat tonight, Monday, December 9, 2002,
will be led by Helene Fisher, SLP.D, CCC-SLP,   Dr. Fisher will lead us in
a chat about cleft palate, VPI, and craniofacial anomalies.  Dr. Fisher is
a Program Instructor specializing in the areas of cleft palate/VPI and
craniofacial anomalies and voice and resonance disorders at Nova Southeastern
University's Communication Sciences and Disorders Department.

<Robin> Welcome!  We are chatting tonight with Helene Fisher, SLP.D., CCC-SLP, about
          cleft palate, VPI, and craniofacial anomalies.
<HeleneFisherNSU> I am a Program Instructor at Nova Southeastern University,
          Fort Lauderdale, Florida. I specialize in Voice/resonance disorders and
          craniofacial Anomlaies. Thank you for having me back as guest speaker.
<Robin> Thank YOU for joining us again!  Dr. Fisher is a wonderful speaker ...I took one
          of her continuing ed. classes a few years ago.
<HeleneFisherNSU> How about I give you all a brief overview of the exciting world of
          cleft palate/VPI and craniofacial anomalies?
<coryvette> sounds good!
<sashabu> OK...just finished this course!
<RobinS> perfect!
<AdrienneFSU> good
<HeleneFisherNSU> OK. Children born with a cleft palate face many challenges as they
          relate to Cosmesis (appearances), dental development, and most importantly of
          all..... speech, language resonance, feeding and hearing.
<HeleneFisherNSU> A cleft is an opening in the hard and or soft palate and or lip.
<HeleneFisherNSU> This opening is caused by a lack of fusion that should have occurred
          during the first trimester of fetal development.
<HeleneFisherNSU> The cause (etiology) can be multifactorial, e.g. genetic disorder,
          tongue getting in the way of palatal fusion, or embryological arrest due to
          maternal illness, or other factors.
<AdrienneFSU> Can this be detected before birth?
<HeleneFisherNSU> Yes. A cleft can be observed on ultrasound.
<HeleneFisherNSU> There are different types of clefts, e.g., a cleft of only the soft
          tissue of the lip = "incomlete cleft lip"
<HeleneFisherNSU> A baby can have a unilateral or bilateral cleft lip.
<HeleneFisherNSU> How do you think an incomplete cleft lip will affect feeding?
<sashabu> Sucking is compromised, formula drips out...
<HeleneFisherNSU> Good point. However, due to the amazing versatility of the orbicularis
          muscles (around the mouth), and the fact that the lips do not play that big a
          role in suckling, feeding is actually not a problem!
<sashabu> Hmmm.......so formula doesn't seep out?
<RobinS> How early will they operate to try to rectify this?
<HeleneFisherNSU> Surgery for the soft tissue of the lip only usually occurs at  months,
          or the 10/10/10 rule. Anybody know what that is?
<sashabu> forgot......
<RobinS> new to this - don't know yet
<HeleneFisherNSU> 10 weeks, 10 lbs, 10 of hemoglobin
<AdrienneFSU> yeah
<sashabu> right!
<RobinS> interesting!
<HeleneFisherNSU> If the cleft penetrates the hard gum ridge as well as the soft lip
          tissue, then that's called a cleft of the primary palate or cleft alveolus.
<Robin> When is surgery for cleft alveolus performed?
<RobinS> Then are feeding issues more of a problem?
<HeleneFisherNSU> Good questions. Yes. this type of cleft will create a communication
          between the oral cavity and nasal cavities. That means it will be very difficult
          to create negative pressure in the oral cavity for suction.
<HeleneFisherNSU> In addition, once the liquid enters the mouth, it leaks through the
          nose = "nasal regurgitation".
<HeleneFisherNSU> This can be quite a challenge for SLPs who need to get this baby to
          weigh at least 10 lbs in order to undergo surgical closure of the cleft lip.
<RobinS> That must be difficult - when is this surgery? and what are alternative feeding
<coryvette> Usually, a special nipple is used on a bottle to aid with feeding, correct?
<sashabu> or a bigger cross cut?
<HeleneFisherNSU> Yes. Correct. Special feeding utensils have to be employed.
          Unfortunately, breast feeding is nearly impossible. The Haberman feeder, Meade
          Johnson feeder, soft and cross-cut nipples are usually the best way to go.
<RobinS> so this one also goes by the 10-10-10 rule!
<HeleneFisherNSU> Sometimes, feeding is so hard, that the baby burns more calories
          trying to suckle!
<Robin> Exactly...my nephew with Cerebral palsy has had those issues...
<HeleneFisherNSU> Of course, if the baby is failing to thrive, additional help is
          required. What might that be?
<RobinS> intravenous??
<Robin> feeding tube to supplement
<coryvette> feeding tube
<HeleneFisherNSU> Nasogastric or G-tube feedings. Exactly.
<AdrienneFSU> Can you add calories to the milk?
<AdrienneFSU> Like adding honey or something??
<Robin> Pediasure has a lot of calories.
<HeleneFisherNSU> Now, if the cleft were of the secondary palate, ie, the hard palate
          posterior to the incisive foramne (bumpy part behind two front teeth/medial
          incisors) and the soft palate then the type is called a cleft palate. When the
          secondary palate is involved, then feeding is also, obviously a big problem for
          the same reasons.
<HeleneFisherNSU> But what about hearing?
<HeleneFisherNSU> When there is a cleft of the soft palate, the baby will have
          Eustachian Tube dysfunction.
<HeleneFisherNSU> What are the implictaions of this?
<AdrienneFSU> Less drainage from the ears.
<coryvette> Usually has Otitis Media with Effusion, too!
<HeleneFisherNSU> Excellent! Chronic ototis media. What can result from this?
<coryvette> Many of these kids fail the hearing screenings, too.
<cory>vette> myringotomy
<RobinS> Are VT's (ventilation tubes) put in at an early age to avoid this and help
<HeleneFisherNSU> Yes. They will have PE tubes put in at 3 months-the same time as the
          soft lip tissue repair.
<HeleneFisherNSU> But tell me, what other serious disorder(s) can develop from chronic
          otitis media and a chronic conductive hearing loss?
<coryvette> Delayed speech and language!
<HeleneFisherNSU> Exactly! Delayed phonology, language and learning!
<HeleneFisherNSU> Now let's talk about what speech/resonance problems occur when the
          mouth and nose are connected. Any ideas?
<coryvette> hypernasality
<AdrienneFSU> hypernasality
<HeleneFisherNSU> Very good! Hypernasality. What else?
<coryvette> velophyarygeal insufficiency
<Susan> inability to complete closure for plosives
<HeleneFisherNSU> VPI can be a complication in about 20% of cases. Very good point,
          however, let's stick with the primary cleft palate for now.
<coryvette> Inability to obtain sufficient air pressure to produce plosives as well
          as /s/ due to the hearing loss.
<Susan> nasal emission
<HeleneFisherNSU> Exactly, Susan. So if children cannot impound oral pressure for high
          pressure sounds like plosives, fricatives and affricates, what will they try to
<coryvette> Substitute with the sounds they are able to produce; decreasing overall
          speech intelligibility.
<AdrienneFSU> Make sounds in the back of the oral cavity?
<HeleneFisherNSU> Wow! Excellent answers! Compensate. And as Adrienne and cory are
          suggesting, they will compensate in a MALadaptive, non-developmental manner.
<HeleneFisherNSU> They will try to make sounds way back in the pharynx or even at the
          glottal level. This process is called "Backing", a non-developmental,
          compensatory pattern.
<HeleneFisherNSU> So, a child who has a communciation between the mouth and nose will
          have hypernasality, nasal air emission, nasal regurgitation, and backing of
<HeleneFisherNSU> Now, cleft palates are usually repaired surgically at - months.
          In about 20% of cases, a VPI will develop.
<HeleneFisherNSU> That means, the velum (soft palate) is too short to reach the
          posterior pharyngeal wall.
<HeleneFisherNSU> That means when the child is producing non-nasal speech sounds, they
          will escape through the nose.
<coryvette> Making it very difficult to decrease hypernasality.
<HeleneFisherNSU> Thus, a child with a VPI, will present with.......??????
<AdrienneFSU> hypernasality still
<coryvette> hypernasality
<Robin> nasal emissions
<HeleneFisherNSU> Yes, and what else?
<coryvette> difficulty with intra-oral air pressure -- the plosives
<coryvette> affricates, and fricatives
<HeleneFisherNSU> And nasal regurgitation
<AdrienneFSU> and swallowing
<HeleneFisherNSU> The VPI child may also try to compensate for inabilty to build up
          positive pressure intraorrally by doing what?
<Susan> continuing maladaptive compensatory behaviors
<HeleneFisherNSU> Exactly, Susan!  Now, if speech therapy does not improve nasal
          resonance, and decrease nasal air emission, then surgery is the next step.
<HeleneFisherNSU> However, PLEASE always refer your child/patient to a Craniofacial Team!!!!!
<AdrienneFSU> What about a prosthesis?
<AdrienneFSU> obturator or something...
<HeleneFisherNSU> Obturator means to plug up an opening.
<HeleneFisherNSU> A prosthesis such as a speech bulb is only used in children with VPI
          associated with cleft palate if they are absolutely not able to undergo surgery.
<AdrienneFSU> ok
<AdrienneFSU> thank you!!
<coryvette> I have a lot of questions about the subject of Pierre Robin Syndrome.
<HeleneFisherNSU> Ok, lets talk about the Pierre Robin Sequence.
<HeleneFisherNSU> While the baby is inutero, if they have micrognathia, ie, a very small
          jaw/mandible, and normal sized tongue, then, when the palatal shelves come
          towards each other in midline, they are unable to fuse because the tongue gets
          in the way.
<HeleneFisherNSU> The baby is then born with a cleft palate, micrognatia, and normal
          sized tongue.
<HeleneFisherNSU> Now the micrognathi presents other problems. Any ideas?
<HeleneFisherNSU> Anybody hear of "glossoptosis"?
<Robin> no
<AdrienneFSU> no
<AdrienneFSU> So the baby needs jaw surgery too?
<HeleneFisherNSU> This is when the tongue falls backwards and obstructs the airway
          because the too small mandible cannot accommodate it and pull the tongue
          forward and out of the way of the upper airway.
<AdrienneFSU> yikes!
<HeleneFisherNSU> Exactly. Jaw surgery such as mandibular distraction osteogenesis,
          or may even need an emergency tracheotomy for fear of sleep apnea or even
          sudden infant death syndrome.
<cory> How long would you keep a client in therapy that had insufficient velopharygeal
          closure in therapy if you suspect he needs additional surgery?
<HeleneFisherNSU> Typically 3 months of intensive speech therapy. However, there
          are techniques that, unfortunately some SLP's are still implementing that have
          been refuted.
<cory> yikes!
<HeleneFisherNSU> For example, blowing, sucking, swallowing exercises will NOT improve
          a VPI.
<cory> true!
<AdrienneFSU> So which techniques DO work?
<Robin> What are some therapy techniques for improving VPI?
<HeleneFisherNSU> Ex's should only include speech acts, correct tongue placement. I also
          include prolonged nasal-cul-de-sac (closing the nostrils).
<AdrienneFSU> like /k/ and /g/ reps?
<HeleneFisherNSU> Adrienne, I'm not following you. Also, Please extinguish all back
          sounds asap.
<HeleneFisherNSU> See-Scape and using the nasometer for visual biofeedback can also be
          helpful. But PLEASE, no blowing, sucking and swallowing.
<cory> okay!
<HeleneFisherNSU> Try and encourage sounds to be made in front of the mouth. Remember,
          the child will have a tendency to back. Work on correct tongue placement for
          all sounds.
<AdrienneFSU> I was thinking it would strengthen the velum...forgot about the backing
          phonological problem..
<HeleneFisherNSU> Good point! Certainly work on velar sounds!
<HeleneFisherNSU> By backing, I mean anything inferior/posterior to the velum. So /k/
          and /g/ are fine.
<cory> If a client has really good tongue placement, is able to produce all sounds in
          connected speech, however, is extremely hypernasal -- what do you do?
<HeleneFisherNSU> Refer to a Craniofacial team. They will probably recommend
          nasopharyngoscopy and videofluoroscpy to examine VP port function.
<cory> Tests were inconclusive
<HeleneFisherNSU> How come? Was the child not cooperating?
<cory> Probably more true than you can ever imagine!  Not sure exactly what happened!
          Parents just reported that the tests were inconclusive.
<HeleneFisherNSU> Another reason for hypernasality in children with repaired cleft
          palates is "dehiscence", ie palatal fistulae (holes in palate) caused by
          breakdown in surgical suture lines.
<cory> Would you recommend dismissing him from speech therapy (after five years with NO
<AdrienneFSU> holy cow
<HeleneFisherNSU> Well, your role as SLP changes. It sounds like ST is not working.
          You need to go the next step and encourage follow up with a craniofacial team.
          This team is made up of many disciplines who will run tests, and determmine the
          next step.
<Robin> Dr. Fisher, tell us about the surgery that is performed to correct VPI and also,
          can additional surgery correct the palatal fisulae?
<HeleneFisherNSU> With neurogenic VPI, and very little velar movement, a palatal lift
          may be considered.
<HeleneFisherNSU> Closure of palatal fistulae is usually a straight forward procedure.
          There are about 8 different techniques for VPI surgery.
<HeleneFisherNSU> Pharyngeal Flap, Sphinctre Pharyngoplasty, Velar Pushback, Implantation,
          Double Z Furlow, etc.
<HeleneFisherNSU> Each procedure has it's pros and cons. Each procedure has its own
          candidacy criteria.
<cory> Tell us more about a palatal lift.
<HeleneFisherNSU> Palatal lift is used for neurogenic VPI. Its a prosthetic appliance
          that is attached to the teeth, and has a "tail" like piece in the back which
          literally lifts up the soft palate.
<cory> It is a useful nonsurgical technique in the patient with palatal paresis, either
          congenital or acquired.
<HeleneFisherNSU> I agree,<cory>.
<HeleneFisherNSU> Many. There is a new procedure happening called NasoAlveolar Molding
          which decreases the number of surgeries . If you are interested in this subject,
          I urge you to take courses. We offer graduate level and CEU courses at NSU, if
          you are interested.
<Robin> Also there can be many procedures done on dentition.
<HeleneFisherNSU> That's right. And the main crux of being on a Craniofacial Team, is
          negotiating with the surgeon and dentists for various procedures that may be
          great for the SLP, but bad for cosmetics and dentition.
<HeleneFisherNSU> For example, as SLP's we would love for the surgeon to close the cleft
          palate asap. However, if this is done too early, maxillary hypoplasia will
<Robin> Well, it is getting late.....are there any more questions for Dr. Fisher?
<AdrienneFSU> Thank you for the discussion Dr. Fisher!
<HeleneFisherNSU> You're very welcome. Good luck to you all in all your future endeavours
          as SLPs!
<Robin> Thank you so much, Dr. Fisher, for sharing your expertise with us...and
          congratulations on receiving your SLPD degree!
<HeleneFisherNSU> Thanks, Robin. Thank you having me.
<RobinS> BEST of luck to you DR. Fisher - hope to see you sometime soon! Good luck all!
<stephanie> Thank you. You were great!
<Susan> Thanks!
<Robin> Thanks to all of you for joining us!
<Robin> Goodnight!