How do we talk and why is it different in children with a cleft?
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Dr Seaward discusses the mechanism for speech, the purpose of the cleft palate repair and why children born with a cleft can struggle to talk even after the cleft is repaired.
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How do we evaluate speech errors in children with a cleft?
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Dr Seaward discusses different types of speech errors and how we determine which types of speech errors a child is struggling with, in order to create a plan to optimize that individual child's speech.
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How do we investigate children with a cleft before speech surgery?
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Dr Seaward discusses speech imaging, the studies we use to determine whether children born with a cleft would benefit from speech surgery and which type would be most appropriate for the individual child.
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Video Scripts:
1.
Hello. Today I would like to discuss how we talk, why children born with a cleft palate can struggle to produce normal sounding speech and what I can do as a cleft speech surgeon to try to get a child to normal speech. I am James Seaward, a pediatric plastic and cleft surgeon at UT Southwestern Medical Center in Dallas, Texas.
So let’s start with how we talk. Looking inside our superhero here, all speech starts with air being pushed out of our lungs. That air makes its way up through the vocal cords, which resonate to give the air a tone and then the air arrives in a space behind the nose and mouth.
Let’s look at this area in more detail. You can see here a face from the side. If we project our view so we are still looking in the same direction but now we are looking at the middle of the face, it will look something like this. You can see the nose and mouth at the front. Between these we have the hard palate, the bony shelf you can feel with your tongue at the top of your mouth. Further back is the soft palate, which has no bone in it but does have muscle, and we will talk more about this in a minute. Other parts of your face involved with speech are your lips, tongue and teeth.
Let’s go back to the air that has been pushed out of the lungs and has resonated through the vocal cords. When it arrives in the space behind the nose and mouth, it can either continue out through the nose or through the mouth. We control which way it goes using the soft palate. Whether or not the soft palate lifts depends on the sound we are trying to make. For most sounds in English, the soft palate lifts up and touches the back of the throat. This acts as a valve system to stop airflow coming out of the nose. Once this valve is activated, we can build up pressure inside our mouth and use our tongue, lips and teeth to shape this pressure into the sounds we recognize as speech.
If this valve system doesn’t work well enough to stop air escaping through the nose, it is called Velopharyngeal Dysfunction, or VPD or VPI for short.
So… why do children born with a cleft have more trouble with this valve system? Well, in an unrepaired cleft there is a complete gap in the middle so until the cleft is repaired the child will have no control about air leaking out of the nose, and often even milk and other drinks will leak out while the child is drinking. The main purpose of the cleft palate repair surgery is to recreate that barrier and to reconstruct the soft palate in a way that results in a well-functioning valve system.
But even after cleft palate repair, some children will have trouble with this valve system. A common problem after cleft palate surgery is that the palate is shortened from scarring. What this means is that even if the palate lifts nicely, it can’t make contact with the back of the throat and air escapes out of the nose. Another common problem is that the muscles are trying to work to lift the palate but they don’t have enough movement to get the palate as high as it needs to be to make contact, allowing air to escape above the palate. One of the most common problems is that as the child has grown since the time of the palate repair, the muscles have moved forward in the palate so they are lifting the palate inefficiently and are unable to make contact and air escapes through the nose.
My job as a cleft speech surgeon is to reconstruct the valve system between the soft palate in a way that is most appropriate for each individual child so that the child can close off air escaping through the nose and can make the speech sounds he or she is trying to make.
In my next video, I will discuss how my speech team and I evaluate each child to determine whether surgery would be helpful and how to decide which type of speech surgery will be appropriate for each individual child.
1.
Hello. Today I would like to discuss how we talk, why children born with a cleft palate can struggle to produce normal sounding speech and what I can do as a cleft speech surgeon to try to get a child to normal speech. I am James Seaward, a pediatric plastic and cleft surgeon at UT Southwestern Medical Center in Dallas, Texas.
So let’s start with how we talk. Looking inside our superhero here, all speech starts with air being pushed out of our lungs. That air makes its way up through the vocal cords, which resonate to give the air a tone and then the air arrives in a space behind the nose and mouth.
Let’s look at this area in more detail. You can see here a face from the side. If we project our view so we are still looking in the same direction but now we are looking at the middle of the face, it will look something like this. You can see the nose and mouth at the front. Between these we have the hard palate, the bony shelf you can feel with your tongue at the top of your mouth. Further back is the soft palate, which has no bone in it but does have muscle, and we will talk more about this in a minute. Other parts of your face involved with speech are your lips, tongue and teeth.
Let’s go back to the air that has been pushed out of the lungs and has resonated through the vocal cords. When it arrives in the space behind the nose and mouth, it can either continue out through the nose or through the mouth. We control which way it goes using the soft palate. Whether or not the soft palate lifts depends on the sound we are trying to make. For most sounds in English, the soft palate lifts up and touches the back of the throat. This acts as a valve system to stop airflow coming out of the nose. Once this valve is activated, we can build up pressure inside our mouth and use our tongue, lips and teeth to shape this pressure into the sounds we recognize as speech.
If this valve system doesn’t work well enough to stop air escaping through the nose, it is called Velopharyngeal Dysfunction, or VPD or VPI for short.
So… why do children born with a cleft have more trouble with this valve system? Well, in an unrepaired cleft there is a complete gap in the middle so until the cleft is repaired the child will have no control about air leaking out of the nose, and often even milk and other drinks will leak out while the child is drinking. The main purpose of the cleft palate repair surgery is to recreate that barrier and to reconstruct the soft palate in a way that results in a well-functioning valve system.
But even after cleft palate repair, some children will have trouble with this valve system. A common problem after cleft palate surgery is that the palate is shortened from scarring. What this means is that even if the palate lifts nicely, it can’t make contact with the back of the throat and air escapes out of the nose. Another common problem is that the muscles are trying to work to lift the palate but they don’t have enough movement to get the palate as high as it needs to be to make contact, allowing air to escape above the palate. One of the most common problems is that as the child has grown since the time of the palate repair, the muscles have moved forward in the palate so they are lifting the palate inefficiently and are unable to make contact and air escapes through the nose.
My job as a cleft speech surgeon is to reconstruct the valve system between the soft palate in a way that is most appropriate for each individual child so that the child can close off air escaping through the nose and can make the speech sounds he or she is trying to make.
In my next video, I will discuss how my speech team and I evaluate each child to determine whether surgery would be helpful and how to decide which type of speech surgery will be appropriate for each individual child.
2.
Hello. Today I would like to discuss different types of speech errors and how we evaluate children born with a cleft who are struggling with their speech to help to try to get that child to normal speech. I am James Seaward, a pediatric plastic and cleft surgeon at UT Southwestern Medical Center in Dallas, Texas.
In this video, I would like to start with the difference between speech errors caused by resonance and by articulation. Let’s go back to looking at the face from the side. If we project our view so we are still looking in the same direction but now we are looking at the middle of the face, it will look something like this. A resonance error is a type of speech error in which there is an inappropriate amount of air coming out of the mouth or nose for the speech sounds the child is trying to make. For children born with a cleft, this is most commonly but not always too much air escaping out of the nose, and this typically needs to be treated with surgery.
An articulatory speech error is a type of speech error caused by the child using the wrong position of their lips, tongue and teeth for the sound they are trying to make, and there are 3 main reasons that children born with a cleft are more likely to have articulatory errors in their speech. The first is to do with the teeth: let’s consider the ‘eff’ and ‘vee’ sounds ‘f’ and ‘v’. We make these sounds by touching our bottom lip to our top teeth to create a thin stream of air, but children born with a cleft often have a missing tooth at the location of the cleft together with a gap in the bony arch of the upper jaw. This means that they can struggle to make the right size hole in order to make this sound correctly. These errors often improve with bone grafting and orthodontic treatment.
The second is to do with the jaw position: let’s consider the ‘tee’ and ‘dee’ sounds ‘t’ and ‘d’. These sounds are made by the tongue touching the roof of the mouth behind the top teeth, building up pressure behind the tongue and releasing it suddenly. Children born with a cleft may have an upper jaw that grows at a slower rate than the lower jaw and is positioned behind the lower jaw. In this case, they can struggle with moving the tongue so that it can reach the roof of the mouth behind the top teeth. These often improve when orthodontic or orthognathic treatment is complete.
The third type of articulation error is learning new ways to make sounds to compensate for another speech error like a resonance error or the articulations we just discussed. These compensatory errors often need to be addressed using speech therapy.
So how do we work out whether the child has a resonance error that will need surgery to improve, an articulation error that will likely improve on its own, an articulation error that needs speech therapy to improve, or a combination of these?
Well at this point I would like to introduce you to our Cleft Team speech pathologists. These ladies are experienced in listening to children born with a cleft to determine which type of speech errors a child has. They will typically listen to the child in clinic, and take a recording of the speech for the clinical records. Based on what they hear, they will either recommend a program of speech therapy or, if they suspect a resonance problem, they will arrange for speech imaging.
In my next video I will discuss the different types of speech imaging studies we do to determine whether a child would benefit from surgery to help with speech and to help decide which operation is the most appropriate for that individual child.
Hello. Today I would like to discuss different types of speech errors and how we evaluate children born with a cleft who are struggling with their speech to help to try to get that child to normal speech. I am James Seaward, a pediatric plastic and cleft surgeon at UT Southwestern Medical Center in Dallas, Texas.
In this video, I would like to start with the difference between speech errors caused by resonance and by articulation. Let’s go back to looking at the face from the side. If we project our view so we are still looking in the same direction but now we are looking at the middle of the face, it will look something like this. A resonance error is a type of speech error in which there is an inappropriate amount of air coming out of the mouth or nose for the speech sounds the child is trying to make. For children born with a cleft, this is most commonly but not always too much air escaping out of the nose, and this typically needs to be treated with surgery.
An articulatory speech error is a type of speech error caused by the child using the wrong position of their lips, tongue and teeth for the sound they are trying to make, and there are 3 main reasons that children born with a cleft are more likely to have articulatory errors in their speech. The first is to do with the teeth: let’s consider the ‘eff’ and ‘vee’ sounds ‘f’ and ‘v’. We make these sounds by touching our bottom lip to our top teeth to create a thin stream of air, but children born with a cleft often have a missing tooth at the location of the cleft together with a gap in the bony arch of the upper jaw. This means that they can struggle to make the right size hole in order to make this sound correctly. These errors often improve with bone grafting and orthodontic treatment.
The second is to do with the jaw position: let’s consider the ‘tee’ and ‘dee’ sounds ‘t’ and ‘d’. These sounds are made by the tongue touching the roof of the mouth behind the top teeth, building up pressure behind the tongue and releasing it suddenly. Children born with a cleft may have an upper jaw that grows at a slower rate than the lower jaw and is positioned behind the lower jaw. In this case, they can struggle with moving the tongue so that it can reach the roof of the mouth behind the top teeth. These often improve when orthodontic or orthognathic treatment is complete.
The third type of articulation error is learning new ways to make sounds to compensate for another speech error like a resonance error or the articulations we just discussed. These compensatory errors often need to be addressed using speech therapy.
So how do we work out whether the child has a resonance error that will need surgery to improve, an articulation error that will likely improve on its own, an articulation error that needs speech therapy to improve, or a combination of these?
Well at this point I would like to introduce you to our Cleft Team speech pathologists. These ladies are experienced in listening to children born with a cleft to determine which type of speech errors a child has. They will typically listen to the child in clinic, and take a recording of the speech for the clinical records. Based on what they hear, they will either recommend a program of speech therapy or, if they suspect a resonance problem, they will arrange for speech imaging.
In my next video I will discuss the different types of speech imaging studies we do to determine whether a child would benefit from surgery to help with speech and to help decide which operation is the most appropriate for that individual child.
3.
Hello. Today I would like to discuss how we investigate children born with a cleft who are struggling with their speech and whom the cleft speech pathologists suspect have too much air escaping from their nose when they talk. I am James Seaward, a pediatric plastic and cleft surgeon at UT Southwestern Medical Center in Dallas, Texas.
In the last videos, we looked at why children born with a cleft can have too much air coming out of the nose when they speak and that this is a type of resonance error known as velopharyngeal dysfunction, or VPD for short. In this video, I would like to discuss the speech imaging studies we do to work out whether a child would benefit from surgery to help with speech and to help decide which operation is the most appropriate for that individual child.
Once the cleft team speech pathologists have evaluated the child and suspect that the child has VPD, they will usually recommend investigating the way the palate is moving during speech with speech imaging.
This speech imaging consists of two imaging studies. The first is lateral videofluoroscopy. This is an x-ray test in which we look at the palate moving from the side as the child talks. Here you can see a girl looking at some pictures to keep her head still during the study, and the machine that takes the x-ray pictures as she is talking. If we go back to the side view of the middle of the face, which you will remember, the images we get from fluoroscopy are very similar. You can see the hard palate between the mouth and nose, and the soft palate behind. If we now look at the soft palate as this child speaks, you will see that it lifts nicely making good contact with the back of the throat. This is normal movement and is what I aim to achieve. Here are some examples of how this imaging can show problems with this valve system. Here is an example of touch closure, where the soft palate just about reaches the back of the throat but not with enough force to act as an effective valve. Now an example of a small consistent gap… and a larger consistent gap. Finally an example of a palate that really isn’t moving well at all. The information from this study can really help to show which type of surgery is most likely to help for the individual child.
The other type of speech imaging is video nasoendoscopy. In this study, a small camera is placed into the mouth and the nose and we can see the soft palate moving directly. It gives us images like this. Going back to our familiar mid facial diagram, the camera is about here and it is looking at this area, which means that on the picture the back of the throat is at the top and the soft palate is at the bottom. If we look as the child speaks, you can see the soft palate lifting against the throat and making good contact. This is a normal movement pattern. Here is an example of a palate that is lifting but not making contact, with a large gap, an example of a palate that is nearly making contact but has a consistent small gap, and an example of a palate that is just about touching but doesn’t have the force required to create a good valve system. You can see the bubbles as the air forces its way through the valve. This study is very helpful to show differences in palate movement between the right and left sides, and to show the speech mechanism in patients who have had a pharyngeal flap.
For me, making a decision about whether a child would benefit from surgery for speech takes a team. The speech therapist evaluation is very important, and the information from the speech imaging videofluoroscopy and nasoendoscopy shows whether surgery can help, and which type of surgery is most likely to help the individual child. In my next video I will discuss the different types of speech surgery I offer.
Hello. Today I would like to discuss how we investigate children born with a cleft who are struggling with their speech and whom the cleft speech pathologists suspect have too much air escaping from their nose when they talk. I am James Seaward, a pediatric plastic and cleft surgeon at UT Southwestern Medical Center in Dallas, Texas.
In the last videos, we looked at why children born with a cleft can have too much air coming out of the nose when they speak and that this is a type of resonance error known as velopharyngeal dysfunction, or VPD for short. In this video, I would like to discuss the speech imaging studies we do to work out whether a child would benefit from surgery to help with speech and to help decide which operation is the most appropriate for that individual child.
Once the cleft team speech pathologists have evaluated the child and suspect that the child has VPD, they will usually recommend investigating the way the palate is moving during speech with speech imaging.
This speech imaging consists of two imaging studies. The first is lateral videofluoroscopy. This is an x-ray test in which we look at the palate moving from the side as the child talks. Here you can see a girl looking at some pictures to keep her head still during the study, and the machine that takes the x-ray pictures as she is talking. If we go back to the side view of the middle of the face, which you will remember, the images we get from fluoroscopy are very similar. You can see the hard palate between the mouth and nose, and the soft palate behind. If we now look at the soft palate as this child speaks, you will see that it lifts nicely making good contact with the back of the throat. This is normal movement and is what I aim to achieve. Here are some examples of how this imaging can show problems with this valve system. Here is an example of touch closure, where the soft palate just about reaches the back of the throat but not with enough force to act as an effective valve. Now an example of a small consistent gap… and a larger consistent gap. Finally an example of a palate that really isn’t moving well at all. The information from this study can really help to show which type of surgery is most likely to help for the individual child.
The other type of speech imaging is video nasoendoscopy. In this study, a small camera is placed into the mouth and the nose and we can see the soft palate moving directly. It gives us images like this. Going back to our familiar mid facial diagram, the camera is about here and it is looking at this area, which means that on the picture the back of the throat is at the top and the soft palate is at the bottom. If we look as the child speaks, you can see the soft palate lifting against the throat and making good contact. This is a normal movement pattern. Here is an example of a palate that is lifting but not making contact, with a large gap, an example of a palate that is nearly making contact but has a consistent small gap, and an example of a palate that is just about touching but doesn’t have the force required to create a good valve system. You can see the bubbles as the air forces its way through the valve. This study is very helpful to show differences in palate movement between the right and left sides, and to show the speech mechanism in patients who have had a pharyngeal flap.
For me, making a decision about whether a child would benefit from surgery for speech takes a team. The speech therapist evaluation is very important, and the information from the speech imaging videofluoroscopy and nasoendoscopy shows whether surgery can help, and which type of surgery is most likely to help the individual child. In my next video I will discuss the different types of speech surgery I offer.
Video Artwork Attribution: Sagittal view of the facial midline: Pereru (Own work) [CC BY-SA 3.0 (https://creativecommons.org/licenses/by-sa/3.0)], via Wikimedia Commons