Management of children with cleft palate and related speech disorders
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Nasal airflow disorders

Nasal airflow disorders occur commonly in children with cleft palate and / or VPI, and are also sometimes seen as a phonological process in children with normal velopharyngeal structure and function. The flowchart below outlines some nasal airflow disorders. These are explained in more detail in the following section.

 

Nasal air emission

Kummer (2008) states that "nasal air emission occurs when there is an attempt to build up intraoral air pressure for the production of consonants in the presence of a leak in the system (velopharyngeal port or oronasal fistula). Some of the airflow is released through the nose, causing a disruption in the aerodynamic process of speech. NAE is most noted on pressure-sensitive phonemes (plosives, fricatives, affricates). It does not occur during the production of vowels or semivowels because there is no need to build up air pressure for these phonemes. Nasal air emission often occurs with hypernasality, but can also occur with normal resonance." (p. 183)

DVD examples of  speakers with nasal air emission:

  • Kummer (2008) clips 7-05 to 7-11.
  • Trost-Cardamone et al (2005) Audio Clip 3-1, Video Clips 3-2, 3-3.
Nasal air emission (NAE) can be audible or inaudible. If nasal air emission is inaudible, then it can be detected visually by the /s/ mirror test
For best sound quality, use headphones
(wmv 3.5 MB) or the nasal emission test
For best sound quality, use headphones
(wmv 8.2 MB). The mirror test can also be conducted on other phonemes, as in the GOS.SP.ASS.. Whilst it is not obvious in speech, it may be important diagnostically.

Because voiceless consonants are associated with increased oral air pressure, these are more often associated with nasal air emission.

If nasal air emission is due to velopharyngeal insufficiency (physical inability to achieve velopharyngeal closure due to anatomical or structural deficit), then it will usually be present for all pressure-sensitive sounds. Nasal air emission co-occurs with pressure-sensitive sounds. If the pressure sound is replaced by nasal airflow (ie the oral target is not perceptually present), then this would be regarded as a nasal fricative (Henningsson, et al, 2008.).

Nasal air emission can be either an active or a passive process.

Active nasal air emission may be the result of phoneme specific nasal air emission (see below), or occur with the persistence of velopharyngeal inadequacy. One example of this is nasal air emission after adequate surgical repair. In this case the speaker may have incorporated nasal air emission into their phonological system for some or all sounds, so that the learned pattern persists after surgical repair.

Phonene Specific Nasal Emission (PSNE) occurs on sibilant sounds /s z ?, , t?, / (some or all of these sounds). The most commonly affected sounds are /s/ and /z/ (Peterson-Falzone & Graham, 1990). As its name would suggest, PSNE occurs on only specific phonemes, in the presence of normal velopharyngeal closure for other sounds. This is a case of velopharyngeal mislearning – the velopharyngeal system is capable of closure, but nasal air emission on some sounds has been incorporated into the child's phonological system. This is reasonably common in the cleft population, but is also sometimes observed in children with no history of cleft and an intact velopharyngeal mechanism. PSNE is an active process and will respond to therapy.

Passive nasal air emission may result from:

  • A fistula (small hole) in the hard or soft palate, which allows oral air to escape from the nose.
  • Velopharyngeal insufficiency (eg unrepaired cleft palate, VPI following removal of tonsils and adenoids, congenital velopharyngeal disproportion).
  • Velopharyngeal incompetency (eg dysarthria secondary to acquired brain injury).

 

Further Reading

 

Nasal turbulence

Nasal turbulence has been described as a snorting sound. The smaller the velopharyngeal gap, the greater the resistance to the airflow, and therefore the louder the sound that is produced. If the nasal air is leaking through a very narrow opening, the airflow becomes turbulent, and the terms nasal turbulence or nasal rustle may be used.

 

Nasal grimace

Nasal grimace is quite commonly observed accompanying nasal air emissions. This is a behavioural response wherein the child attempts to inhibit the nasal air emission by constricting the nose to reduce the air escape. Nasal grimace can involve just the nares, or can extend to the bridge of the nose, or include the forehead. This may be called facial grimace. Nasal or facial grimace can be distracting to the listener. If nasal grimace does not resolve with treatment of VPI, it should be targeted in therapy (Golding-Kushner, 2001).

 

Further reading

 

 

Disclaimer

This webpage pertains to management of children by the John Hunter Children's Hospital Cleft Palate Team.  The resource information is aimed at qualified speech pathologists working within the geographical area of the Northern Child Health Network. It assumes a working knowledge of articulation and phonological processes in paediatric populations.

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