The speech/language pathologist provides evaluation and treatment of four communication parameters for patients with clefts and craniofacial anomalies, from infancy through adulthood. These parameters include resonance, articulation, phonation, and language development. The goal of the speech/language pathologist is to facilitate normal speech and language development. This is achieved by providing education concerning speech and language development, recommending and providing speech therapy, and as the child matures, by providing more direct perceptual, acoustic, sound pressure, radiologic, and aerodynamic measurements of the velopharyngeal mechanism. Dental, hearing, prosthetic, and surgical interventions must be factored into all management considerations. If velopharyngeal insufficiency is suspected, and palatal management is considered, direct visualization of the velopharyngeal mechanism during speech production is required, with repeat studies following surgical or prosthetic management.

1. Neonatal and Infancy
   1. Monitor and assess feeding, swallowing, and hearing ability.
   2. Discuss the following areas with family: language, cognition, and speech development with and without a cleft palate or palatal dysfunction.
   3. Monitor and stimulate receptive and expressive language and cognitive development.
   4. For babies with cleft palate, facilitate oral communication by emphasizing all vowel sound production and those consonants produced by the lips and anterior tongue, which are nasal, or require little intraoral air pressure (/m/, /n/, /w/, /l/, and "y"). Avoid consonant constrictions that are made in the back of the throat, in the glottal area, or made by the posterior tongue to posterior pharyngeal wall. Also, avoid excessive yelling and screaming.
2. Toddler (< 3 years)
   1. Monitoring the patients' general communication development, motor skills, and cognition.
   2. By this age, patients have usually undergone lip and/or palate repair, and their speech, language, resonance, and voice needs to be assessed with consideration for early speech and/or language therapy; with more global delays, an early childhood program should be instituted.
   3. Nasal consonant substitutions may be observed. These occur when the speech articulators are placed appropriately for the intended oral consonant, but due to incomplete palatal closure, the speech sound is produced as a nasal consonant (/b/ becomes /m/; /d/ becomes /n/).
   4. Compensatory substitutions may be noted. These are unconsciously learned speech patterns that occur when the articulators are positioned inappropriately in an effort to produce oral consonants. These are commonly heard in attempted production of plosives (sounds created by complete blockage of airflow followed by buildup of pressure which is suddenly released, such as /b/) and fricatives (sounds characterized by turbulent noise, such as /s/).

      If adequate oral pressure cannot be achieved with typical placement of the articulators, then an alternative constriction site may be used and pressure is created below the level of constriction. Some common compensatory articulations include:

      1. Glottal stops - closure of the vocal folds at the level of the glottis.
      2. Pharyngeal fricative - posterior positioning of tongue to posterior pharyngeal wall, occurring on fricatives and affricates.
      3. Pharyngeal stop - posterior positioning of lingual base to pharyngeal wall, occurring on /k,g/.
      4. Posterior nasal fricative - coarticulated nasal snort/flutter with any pressure consonant.
      5. Mid-dorsum palatal stop - usually made in an approximate place of consonant /j/ in attempt to valve airflow.
   5. Obturation of any hard palate fistulas may result in elimination of nasal leakage, improved resonance, and VP closure. Use of a speech bulb may be indicated for patients demonstrating reduced intraoral pressure, resulting in difficulty producing pressure consonants despite speech therapy.
   6. Monitor phonation for vocal hoarseness, volume, and pitch levels with speech therapy for remediation or referral to otolaryngology.
3. Preschool, School-Aged, and Adult: As speech articulation is acquired, the speech/language pathologist can begin differential diagnosis of velopharyngeal functioning.
   1. Continued monitoring of hearing acuity.
   2. Speech disorders related to velopharyngeal function.
      1. Hypernasality - the perception of excessive nasal resonance during production of vowels and semi-vowels resulting from inadequate separation of the oral and nasal cavities.
      2. Hyponasality - reduction of normal nasal resonance usually resulting from blockage of nasal airway by various causes.
      3. Mixed hyper/hypo - simultaneous occurrence in the same speaker, usually resulting from incomplete velopharyngeal closure and high nasal resistance that is not sufficient to block nasal resonance completely.
      4. Cul-de-sac - variation of hyponasality associated with tight anterior nasal constriction, often resulting in muffled quality.
      5. Nasal air emission - nasal escape associated with production of high oral pressure consonants. Occurs when air is forced through incompletely closed velopharyngeal port, and can be audible or visible (evidenced by mirror fogging, nasal grimace, and/or nasal flaring).
      6. Compensatory articulations.
      7. Reduced intraoral pressure - reduced build up of air in the oral cavity during production of pressure consonants due to inadequate valving of the VP mechanism.
   3. Phonation: Voice quality, the perceptual characteristics of voice.
      1. Hoarseness - a periodic vibration of the vocal folds producing a "rough" vocal quality.
      2. Breathiness - excessive leakage of air through the glottis during phonation.
      3. Pitch - sound property determined by the frequency of vibration of the vocal folds, either high, optimal, or low.
      4. Volume - acoustic power or intensity.
   4. Assessment
      1. Perceptual
         1. Standardized articulation testing
         2. Assessment of perceived oral-nasal resonance balance during connected speech
      2. Nasometer - nasalance, which provides a numeric output indicating the relative amount of nasal acoustic energy.
      3. Aerodynamic Measurements - pressure flow studies estimating the sectional area of VP orifice (i.e., PERCI).
      4. Assessment of oral structure and function.
         1. Face: symmetrical structure and function; drooling
         2. Lips: degree of bilabial contact, non-speech function, position during quiet breathing
         3. Dentition: occlusion, crossbite, open/closed bite, over/underbite, ectopic teeth, missing, rotated, or supernumerary, dental arch collapse, dental appliances
         4. Tongue: deviation, lobule, frenulum, tongue thrust, non-speech function (range, strength, and symmetry of motion)
         5. Hard palate: height, contour, width, oronasal fistulae
         6. Tonsils/faucial pillars: size, position, and symmetry of tonsils, movement of pillars
         7. Soft palate: symmetry at rest and during phonation; lateral and vertical degree of movement, uvula
         8. Submucous cleft palate: bifid/notched uvula, zona pellucidum or transparency of the palate at midline, bony notching at the posterior border of the hard palate
         9. Pharyngeal walls: vertical/lateral/symmetry of movement
      5. Imaging Studies
         If VP dysfunction is suspected, direct visualization is required to evaluate velopharyngeal functioning during speech production using oral and nasal consonants in words, phrases, and sentences.
         1. Nasopharyngoscopy (videos: occult submucous cleft palate, velopharyngeal insuffiencency; sphincter flap; pharyngeal flap): degree of velopharyngeal closure for speech production and swallowing, velopharyngeal closure pattern, symmetry, velar contour, movement (velum, lateral pharyngeal and posterior pharyngeal walls, Passavant's ridge), adenoids/tonsils, laryngeal structure, and function
         2. Multiview videofluoroscopy
      6. A midsagittal lateral view: movement of the velum and posterior pharyngeal walls, height and length of velum, point of velar closure, and velar relationship to adenoids and posterior pharyngeal wall; posterior tongue valving
      7. Frontal view: lateral pharyngeal wall movement
      8. Basal/Towne's view: all of the above, except vertical movement

The speech/language pathologist reviews both perceived speech characteristics and physiological status of the velopharyngeal mechanism during speech production, with possible recommendations for surgical or prosthetic management, speech therapy, and/or continued monitoring of VP function. If surgical management is recommended, perceptual evaluation should occur 3-6 months following surgery, with repeat imaging studies 6-12 months post management. Speech therapy for VP function should be deferred for 6-12 weeks following secondary palatal management, while therapy for developmental or compensatory articulations may be resumed in 3-4 weeks.

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