ASSESSMENT OF CLEFT LIP AND PALATE

- Bhoomika and Nasima

Communication problems are common in individuals with cleft lip and palate. Successful
surgery in early months of life and an effective multidisciplinary approach in later years are
important for minimizing the associated problems, however, most people with cleft palate still
have communication stigmas associated with cleft lip and/or palate. Communication disorders in
cleft palate are typical, complicated, and present significant challenges including:

 Delayed speech and language development.

 Articulation disorders: Articulation disorders in cleft palate can be classified follow
cleft type characteristics (CTCs) follow as (John et al. 2006)
 Anterior oral CTCs: dentalization/ inter-dentalization, lateralization/lateral,
palatalization/palatal
 Posterior oral CTCs: double articulation, back to velar/uvular.
 Non oral CTCs: pharyngeal articulation, glottal articulation, active nasal fricatives,
double articulation.
 Passive CTCs: weak and or nasalized consonants, nasal realization of plosives, and/or
suspected passive nasal fricative, gliding of fricatives/affricates
 Non-cleft speech immaturity/errors.
 Voice disorders from laryngeal hyperfunction in an attempt to compensate for acoustic
effects of velopharyngeal dysfunction or compensatory articulation of glottal stops.
 Deviant resonance and nasal airflow from velopharyngeal insufficiency (VPI).
 Hypernasality
 Hypernasality
 Nasal emission
 Nasal turbulence

There are several protocols and methods that exist for evaluating speech and language disorders
in cleft palate. These include perceptual speech assessments, intraoral examination, language
assessments, articulation tests, universal parameter tests for standard speech reporting , acoustic
analysis (e.g., spectrography, the oral-nasal acoustic ratio), aerodynamic measurements,
observation of structure movement (e.g., nasopharyngoscopy, videofluoroscpoy,
electromyography). This article aims to summarize the evaluation of speech and language
disorders in individuals with cleft lip and/or palate.

Evaluation of language
Various and broad language assessment tools have been in use for several years in many
languages. It is important to keep in mind that these tools should have validity and reliability.
Periodic language evaluation is recommended for appropriate tests and times (Estrem Broen
1989, Scherer and D'Antonio 1995, American Cleft Palate-Craniofacial Association 1993) due to
clinic visit protocols. For infants and toddlers from age for 0-18 months, assessment of early
communication skills and language development focuses on 3 major areas of communicative
behavior: parent-child interaction, early social communication skills, and receptive and
expressive language skills (Girolannetto 1995). For preschool children, a number of tests have
been developed for language assessment (Werner andKresheck 1983, Carrow-Woolfolk 1985,
Gardner 1990, Reynell and Grube 1990). These tools can be generally used for both typical
children and children with risk for delayed speech and language development including
individuals with cleft lip and palate.

Various language tests were developed for the assessment of language and its components. Some
of the tests developed are: REELS, 3D-LAT, KLT/MLT and LPT

REELS: The Receptive Expressive Emergent Language Scale was given by KENNETH R.,
BZOCH and RICHARD LEAGUE in the year 1971.

Age group: 0 to 36months

Age interval: 1 month in the first year

2months in the second year
3 months in the third year
The test emphasizes the process of receptive language, expressive language and inner language.

3D-LAT: Three dimensional language acquisition test

This test was developed by GEETHA HARLEKHAR, 1986.

Age group: 9 months to 36 months

Age interval : 2 months up to 32 months and 3 months for last group

This scale assesses the following three dimensions:

RECEPTION
EXPRESSION
COGNITION

Similarly other tests such as KLT/MLT (Kannada language test/ Malayalam language test) and
LPT (Linguistic profile test) are developed for the assessment of language and its components in
various Indian languages.

Evaluation of speech disorders

Systems for the assessment of cleft speech disorders have been developed to elicit cleft-type
speech characteristics and have been available for use for many years. Both perceptual and
instrumental assessments exist and are used for reporting speech outcomes. Recent assessments
have contained a cross-country, universal, and an international system, for example, a perceptual
assessment system in Sweden (Dotevall 2002); the Swedish Articulation and Nasality Test
(SVANTE) (Lohmander et al. 2005); speech assessment in the Scandcleft Project (Lohmander
2009); the cleft audit-protocol for speech, augmented (CAPS-A), an updated version of the
original CAPS, that measures cleft-type speech characteristics and records these using a traffic
light system which aims to meet the needs of both outcome data and future treatment needs (John
2006); and the system of universal parameters for reporting speech outcome (Henningsson
2008). This later system is an easy method which is comparable across cleft centers and
countries. Each center in any country can establish a speech sample that follows the guidelines
for assessing speech disorders. Reliability should always be done to standardize methodology in
each center.
Overall, most cleft palate speech assessments generally contain universal speech parameters
including:
 Hypernasality
 Hyponasality
 Audible nasal air emission and/or nasal turbulence
 Consonant production errors
 Voice disorder
 Speech intelligibility/ understandability/ acceptability.
Assessment involves the assessment of both speech and language.
Under speech evaluation articulation, voice, resonance, speech intelligibility and velopharyngeal
dysfunction are assessed.
Under language assessment both reception and expression are assessed.
Assessment of speech involves two types: Subjective and Objective assessments.
Subjective assessment refers to the use of test batteries, scales etc.
Objective assessment refers to the use of instruments for the process of assessment.

VARIOUS ASSESSMENT PROCEDURES

1. ORAL PERIPHERAL MECHANISM EXAMINATION
An oro-facial examination starts with observation of the external anatomy, particularly the
anatomy of the face. The facial structure should be first observed in rest. The facial gestures, the
tongue should beexamined properly. Along with it nose, eyes, ears should be examined.

EYES
The spacing between the eyes can be abnormal in certain craniofacial syndrome.
e.g
 An individual with a craniofacial syndrome may demonstrate excessive spacing between
the eyes, which is called as HYPERTELORISM
 EARS
The shape and location of the ears should be observed. Many craniofacial syndromes
include malformed ears, such simplified helix, or microtia. This is often accompanied by
aural atresia. Aural atresia usually result in conductive hearing loss, and this could have
an impact on quality of speech and possibly resonance when it’s bilateral.

NOSE AND AIRWAY

 The nasal bridge, or nasion, is the bony structure that is located between the eyes and
corresponds to the nasofrontal suture. This structure should be examined because a flat
nasal bridge can affect the nasal airway, causing upper airway obstruction and
hyponasality.
 A bulbous nasal tip is often associated with syndrome.
 When there was a unilateral cleft lip and palate, septal deviations often occur. Upper
airway obstruction can cause a chronic open mouth posture and anterior tongue position,
which can ultimately result in an anterior open bite. The mandible may be positioned
down and forwarded in order to open the airway further.
 Other characteristics of upper airway obstruction include suborbital coloring, which
makes the patient appear to be tire, pinched nostril. These characteristics are referred as
“adenoid facies”.
ASSESEMENT OF NASAL AIRWAY
To test the nasal airway, the examiner can ask the patient to close the lips and breathe nasally for
several minutes. The examiner should observe whether there is any difficulty with nasal
breathing. Prior to the opening the mouth, the patient should then inspire deeply through the
nose, and then exhale through the nose. Again the examiner should observe any difficulty.
The patency of each nostril can be assessed by having the child close one nostril and then
forcibly inspire through the other nostril. If there is obstruction this will be difficult to do and
result in high pitch sound.
Another test is to ask the patient to prolong /m/ with the lips closed to see if there is blockage. If
there is significant blockage, the patient wil be unable to do this easily.

FACIAL BONES AND PROFILE

The bony structures of the face are important to assess, particularly as they relate to each other.
Flattened zygomas, are often seen in individuals with history with cleft lip and palate or other
craniofacial syndromes.
The facial profile can give an indication of the dysmorphology of other facial bones. This can be
evaluate by having the patient turn so that the examiner is viewing the side of the person’s face.
Discripancy in the relationship between the maxilla and mandible can be particularly problematic
for speech. Since the tongue always resides within the arch of the mandible, the position of the
maxilla in relationship to the mandible can affect the amount of space available for the tongue tip
to articulate.

LIPS
The lips should be assessed for the ability to achieve bilabial at rest and during speech. If the
upper lip is short relative to the length of the maxilla, bilabial closure may be difficult to achieve
and maintain. The lip may even be relatively short due to a protruding pre-maxilla. As a result
during the production of bilabial sounds, the individual may substitute labiodental sounds.
When there is a history of cleft lip and palate, there may be excess of scarring, the Cupid’s bow
may be asymmetrical or flat, or the vermilion may extend into the philtral suture lines.
The examiner should always look for lop its, which are small depression in the bottom lip.
There may be reduced mobility of the lips due to scarring. To assess labial movements, the
patient may be asked to sustain exaggerated /i/ and /u/ sounds. The examiner should observe the
symmetry and range of lip and facial movements.

HARD PALATE
To examine the hard palate, it is best to have the patient put the head back as far as
possible so that the entire hard palate and velum can be visualized.
Once the palate can be seen, the mucosa of hard should be observed. It should be uniform
in color.
As a part of examination, the position of alveolar ridge, as it relates to the position of the
tongue tip, should be determined. Alveolar ridge is not just above the tongue tip, as
commonly occurs when there is significant maxillary retrusion or protrusion, difficulty
with the production of lingual-alveolar sounds might be expected.
The palatal vault should also be evaluated, especially in relationship to the size of tongue.
If the patient has a history of cleft lip and palate, the examiner should rule out the
presence of oro-nasal fistula in the line of the cleft .A tongue flap, which is used to close
a large fistula may be noted.
VELUM AND UVULA
In an intraoral examination, the clinician should examine the velar integrity. If there is
repaired cleft palate, it is important to rule out whether is a fistula in the velum in
addition to the hard palate. The position of the fistula relative to the velar dimple is
important to determine.
If there is no history of cleft palate, the examiner should always look for sub mucous
cleft.

TONGUE
Both the structure and function should be assessed. The size of the tongue should be
evaluated in relationship to the mandibular arch, the palatal arch and the overall cavity
space. Infant’s tongue is considerably larger when compared to oral cavity space than the
tongue of an older child or adult. The tongue reaches maturation at the age of around
eight years. If the tongue is significantly larger than the oral cavity space so that it
doesn’t fit with attempts to close the teeth, this might indicate macroglossia.
The tongue should be evaluated for multiple lobes if there is a history of a syndrome.
The lingual frenulum under the tongue should be inspected for its location of attachment
if there is ankyloglossia, the tongue tip will course inward during protrusion so that it
resembles the top of a heart.
 EPIGLOTTIS
The epiglottis can often be viewed during an intraoral assessment f a young child as he
protrudes the tongue to say ‘’aah’’.The epiglottis is located just below the base of the
tongue and is relatively high in the hypopharynx in young children.

STRUCTURE  APPEARANCE FUNCTION

1)LIP  COLOUR NORMAL ROUNDING-ADEQUATE
 SYMMETRY PROTRUSION-
 SIZE ADEQUATERETRACTION-
ADEQUATE (i,u)

 POSITION AT CLOSE LIPSEAL WHILE PUFFING

REST CO ORDINATION (i, u)
WHILE SAYING (i,u)
(adequate)

2)JAW  SYMMETRY NORMAL RESISTANCE-NORMAL

 SIZE NORMAL AGAINST PRESSURE
NORMAL RANGE OF OPENING-
 MAXILLA
NORMAL ADEQUATE
 MANDIBLE

PROTRUTION- NORMAL
RETRACTION- NORMAL
3)TONGUE  COLOUR NORMAL LATERAL- NORMAL
 SIZE NORMAL ELEVATION -NORMAL
 TREMORS NORMAL ALTERNATE
MOVEMENT WHILE
SAYING k ,t –normal
TONGUE STRENGTH-
NORMAL

4)TEETH  COLOUR NORMAL

 MISSING TEETH ABSENT
 OCCLUSION NORMAL

5)HARD  ARCH NORMAL

PALATE  CLEFT ABSENT
 SYMMETRY NORMAL
ELEVATIN-NORMAL
STRENGTH OF VELAR
 CLOSURE NORMAL CLOSURE WHILE
6)SOFT  SYMMETRY NORMAL PUFFING CHEEKS-
PALATE  CLEFT NORMAL NORMAL
CLASSIFICATION OF CLEFT LIP AND PALATE
SRIPED Y CLASSIFICATION

MODIFIED STRIPED-Y ELSAHY CLASSIFICATION: Elsahy modified Kernahan Striped –

Y classification in 1973 by recording more details.

 Triangle 1 represents the fusion line between the maxillary prominence and
medial nasal prominence at nostril floor level on right side while triangle 5
represents the fusion line between the maxillary prominence and medial nasal
prominence on the left side at the nostril floor level.
 Square 2 represents the fusion line between the maxillary prominence and
medial nasal prominence at upper lip level on the right side while square 6
represents the fusion line between the maxillary prominence and medial nasal
prominence at upper lip level on the left side.
 Square 3 represents the right alveolus while square 7 represents the left
alveolus (fusion line between the maxillary prominence and intermaxillary
segment).
 Square 4 and 8 represents the fusion line between primary and secondary
hard palate (which lies anterior to the incisive foramen) on the right and left
side respectively.
 Squares 9 and 10 represents the fusion line between palatine shelves of hard
palate and lies posterior to the incisive foramen.
  Square 11 represents the soft palate.
 Circle 12 represents the posterior pharyngeal wall.
 Circle 13 represents the pre-maxilla.

For example:

I. SUBJECTIVE ASSESSMENT
ASSESSEMENT PROCEDURE: SPEECH AND LANGUAGE
1. LANGUAGE EVALUATION
LANGUAGE SCREENING
As children with a history of cleft or craniofacial anomalies are at a risk of early language delay, it is
important that these children receive regular language screening throughout pre-school years. If language
problem is suspected from screening evaluation, a comprehensive language evaluation should be done. A
comprehensive should also be done if a child has additional risk factor for language disorder, such as
hearing loss, developmental delay, or neurological problem.

INFORMAL LANGUAGE SCREENING

Informal screening can be done by
 Observing play behaviors, and the type and complexity of gestures.
 Asking the child to point to certain objects or follow certain commands.
 Having interesting toys available and observing spontaneous vocalization and utterance.
 Listening to the child’s spontaneous speech while he or she is talking to the parent
 Asking question or asking for explanations
e.g
What do you want to be when you grow up? Why?
What does a policeman do?
  Having the child repeat sentence, such as those listed in the articulation What
does a fireman do? what does a teacher do? what screening test. Even in
repeating, the child will usually revert to his or her own form of syntax and
morphology, which gives an indication of expressive language abilities.

Through this simple method, the examiner should be able to determine the
primary mode of communication. If the child is communicating with sentence, the
examiner should able to determine whether the sentences are complete or merely
telegraphic, whether there are errors of syntax or morphology, what is the MLU.

FORMAL LANGUAGE SCREENING TESTS

There are several formal screening tests that allow screening tests that allow the
examiner to sample the child’s communication abilities using a structured format.
Some examples of screening tests are:
 Receptive-Expressive Emergent Language Scale
 Early Language Milestone
 Rossetti Infant-Toddler Language Scale

These tests are used to screen children from birth to three years through observation and present
reports.
 The Fluharty Preschool Speech and Language Screening Test (Fluharty,1978) :
Is used to screen children from the age of 2 to 6 in the areas of articulation.

2. SPEECH ASSESEMENT
When assessing articulation, resonance, and velopharyngeal function, it is important to select an
appropriate speech sample to obtain the information that is needed for a definitive diagnosis.
When testing a child, the speech sample must also be developmentally appropriate in the areas of
speech sound production and syntax.

ASSESSMENT OF ARTICULATION
The speech evaluation should begin with an articulation test. This helps in determining the cause
of the speech problem.
Tests like the IOWA Pressure Articulation Test, PB Articulation Test and the Bzoch Error
Pattern Diagnostic Articulation Test were specifically designed to assess the effects of VPI.
 IOWA Pressure Articulation Test: This test involves assessment with respect to position
(initial, medial and final) and the types of error.
 Bzoch Error Pattern Test: Involves 100 words divided as blends and consonants. Errors
such as gross substitution, simple substitution, omission and distortion are assessed in
this.
  PB Articulation Test: This involves assessment of /p/ and /b/ in all the positions.

FORMAL ARTICULATION TEST

The speech evaluation should begin with an articulation test.
Purpose of articulation test are:

 To determine the cause of speech problem (structure versus function).

 To provide data that the clinician can use to develop an appropriate treatment
plan for therapy.

SYLLABLE REPETITION
 This is used to test phonemes at the syllable level to isolate the effects of other sounds
and to determine if there is phoneme-specific nasal air emission.
 Done by making the child produce consonant phonemes (fricatives, plosives and
affricates) in a repetitive manner (i.e., pa, pa, pa; pee, pee, pee; ta, ta, ta; tee, tee, tee etc).
 This helps in assessing both articulation and presence of nasal air emission on individual
phoneme.
 Also helps the examiner to determine whether hypernasality occurs more on high vowels
than on low vowels or whether vowel-specific.

SENTENCE REPETITION
 The examiner should have a battery of sentences that test each consonant phoneme
similar in articulatory placement (such as “Take Teddy to Town”).
 The child is made to repeat these sentences and articulation, nasal emission and
resonance in a connected speech environment are tested.
 While evaluating for nasal emission, the sample should contain many pressure-sensitive
consonants (“Sissy sees the sun in the sky”).
 While testing for hypernasality, the sample should contain a high number of voiced, oral
sounds and sentences with high frequency of nasal phonemes (“My mama made
lemonade for me”).
 To rule out the nasal air emission or compensatory errors, low-pressure consonants ( How
are you? Where are you?) etc are used.
 Counting from 60 to 70 or simply repeating 60, 60, 60 also helps as it requires a build-up
and continuation of intraoral air pressure.
The following characteristics have to be evaluated by merely listening to spontaneous speech
or repetition of sentences:
ARTICULATION: The type of errors, compensatory articulation and the manner of articulation
should be assessed. The child can be asked to repeat and the examiner watches for the production
of each phoneme.
STIMULABILITY: Articulation errors that cause nasal air emission or hypernasality are the
result of faulty placement. Hence change in articulatory placement has to be done and care
should be taken to see that the child is able to produce sound without nasal air emission.
NASAL AIR EMISSION: It is important to determine whether nasal emission is of low
intensity which is the result of large velopharyngeal opening or whether it is ‘bubbly’ nasal rustle
(turbulence) which is the result of small opening.
WEAK CONSONANTS: These are usually associated with both nasal air emission and
hypernasality. Hence evaluation is done by listening to the force of production of the pressure-
sensitive consonants.
SHORT UTTERANCE LENGTH: If there is significant nasal air emission, it can also have an
effect on utterance length. This is determined by observing the phrasing of utterances in
connected speech. This can be done by asking the client to count to 20.
ORAL-MOTOR DYSFUNCTION: This is common in individuals with craniofacial
syndromes. Characteristics of velopharyngeal dysfunction may occur as a result of apraxia of
speech. This can cause errors in closing of the valve for oral sounds and opening of valve for
nasal sounds. The difference in resonance between short, simple and longer utterances have to be
noted.
RESONANCE: This has to be judged as either normal, hypernasal, hyponasal, dental, cul-de-sac
or mixed by listening to spontaneous speech.
PHONATION: Dysphonia is common in individuals with VPI or craniofacial anomalies.
Therefore dysphonia, including hoarseness, breathiness, glottal fry, hard glottal attack,
inappropriate pitch level, restricted pitch range etc., have to be looked for.

MATERIAL DEVELOPMENT FOR ARTICULATION: Construction of

articulation test.
 The first step in developing an articulation test is to collect the commonly used words in a
language.
 The words should also consist of the commonly used sounds in the initial, middle and
final position.
 The collection of the words should be given to a SLP who is a native speaker of the
language, in order to choose the most occuring sounds.
 And rate the usage of words in the scale of 1-5. This is called context validation.
 The final material should then be prepared and administered on 30 normal people of each
age group.
 Test of reliability and validity across various populations from different socio-economics
status, age group should also be done.
 II. OBJECTIVE ASSESSMENT
USE OF LOW-TECH DEVICES
The evaluation can also be done using low-tech devices which are helpful too.
VISUAL DETECTION
 Mirror test
 Air paddle
 See scape
These can be used to check for nasal emission during the production of pressure-sensitive
sounds.

TACTILE DETECTION
 Feeling from the sides of the nose: Vibration from hypernasality and nasal air emission
can be felt by placing the index fingers lightly on the individual’s nose, in the area of the
cartilage.

AUDITORY DETECTION
 Nose pinch: also called the “Cul-de-sac Test” by Bzoch.
 Stethoscope
 Straw
 Listening tube
These help in detecting hypernasality and nasal emission.

USE OF HIGH-TECH DEVICES

Electropalatogram
Electropalatography (EPG) is a technique used to monitor contacts between the tongue and hard
palate, particularly during articulation and speech. A custom-made artificial palate is molded to
fit against a speaker's hard palate. The artificial palate contains electrodes exposed to the lingual
surface. When contact occurs between the tongue surface and any of the electrodes, particularly
between the lateral margins of the tongue and the borders of the hard palate, electronic signals
are sent to an external processing unit. EPG provides dynamic real-time visual feedback of the
location and timing of tongue contacts with the hard palate.

This procedure can record details of tongue activity during speech. It can provide direct
articulatory information that children can use in therapy to monitor and improve their articulation
patterns. Visual feedback is very important in the success of treating deaf children.
Effectiveness in Therapy
Electropalatography has been studied in a variety of populations, including children with cleft
palate, children with Down syndrome, children who are deaf, children with cochlear implants,
children with cerebral palsy and adults with Parkinson's disease. Therapy has proved to be
successful in tested population. Longitudinal studies with large sample sizes are needed to
determine the long-term success of therapy.
ASSESSMENT OF VOICE
CAPE-V
Provides a perceptual judgment on voice parameters and rate the severity. The
Consensus Auditory-Perceptual Evaluation of Voice (CAPE-V) was developed as a tool
for clinical auditory-perceptual assessment of voice. Its primary purpose is to describe the
severity of auditory-perceptual attributes of a voice problem, in a way that can be
communicated among clinicians. Its secondary purpose is to contribute to hypotheses
regarding the anatomic and physiological bases of voice problems and to evaluate the
need for additional testing.

Definitions of Vocal Attributes:

OVERALL SEVERITY: Global, integrated impression of voice deviance.
Roughness: Perceived irregularity in the voicing source.
Breathiness: Audible air escape in the voice.
Strain: Perception of excessive vocal effort (hyperfunction).
Pitch: Perceptual correlate of fundamental frequency. This scale rates whether the
individual's pitch deviates from normal for that person's gender, age, and referent culture.
The direction of deviance (high or low) should be indicated in the blank provided above
the scale.
Loudness: Perceptual correlate of sound intensity. This scale indicates whether the
individual's loudness deviates from normal for that person's gender, age, and referent
culture. The direction of deviance (soft or loud) should be indicated in the blank provided

above the table.

GRBSA SCALE
In diagnosing voice disorders, a description is obtained of the patient’s chief complaints,
present illness, degree and quality of hoarseness, past history, occupation, and voice-
related daily habits or social background. Useful in this are two simple-to-perform
examinations that do not require special instruments: auditory-perceptual evaluation
using the GRBAS (Grade, Roughness, Breathiness, Asthenia, Strain) scale and
measurement of maximum phonation time (MPT).

Grading: Grading is done by correlating the scores and the factors considered.
For example:
Considering the above table, the grade of each patient can be given as:
Patient 1: G1R1B1A1S0
Patient 2: G0R0B0A0S0
Patient 3: G1R1B1A1S0 and so on.