Comprehensive Assessment for Cleft Lip and Palate: Typical Components

• Family history of cleft palate and/or speech and language disorders.
• Prenatal and birth/delivery history.
• Developmental history.
• Medical history, including
  • history of ear infections/fluid;
  • history of ventilation tube placement;
  • medical diagnoses;
  • syndromic diagnosis; and
  • surgical history.
• Concerns regarding
  • feeding;
  • breathing or snoring; and
  • hearing loss.
• Family's and other communication partners' perception of speech intelligibility and resonance.
• Teacher's perception of child's speech and how it compares with the speech of peers in the classroom.
• History of speech and language therapy.
• Psychosocial concerns or issues.
• Family's perspectives on their quality of life.
• Individual's perspectives on his or her quality of life (see, e.g., Hall, Gibson, James, & Rodd, 2013).

• Otoscopic examination.
• Immittance testing to assess middle ear function.
• Pure-tone air and bone conduction to determine presence and type of hearing loss.
• Otoacoustic emissions testing to assess outer hair cell function.
• Speech detection threshold.
• Speech recognition (closed or open set, depending on age).

See ASHA's Practice Portal page, Hearing Loss in Children, for information about full audiologic assessment conducted by an audiologist.

• When feeding difficulties are significant and signs of airway compromise are evident, objective studies may be conducted to assess the infant's ability to feed safely.
• Feeding assessment and expectations are based on the child's age, neurologic and developmental status, and whether or not palate repair has been completed.

For more details, see ASHA’s Practice Portal page, Pediatric Feeding and Swallowing.

• Visually examine the child for structural differences/abnormalities (e.g., proportion and symmetry) of the craniofacial complex (including face, nose, eyes, ears, skull, and profile).
• Inquire about the presence of atypical nasal congestion.
• Assess oral cavity for
  • symmetry and movement of oral structures (lips, jaw, tongue, velum);
  • abnormalities of the tongue (e.g., macroglossia, akyloglossia, asymmetry);
  • presence and size of tonsillar tissue (large tonsils can play a role in airway and resonance problems);
  • dentition and occlusal status;
  • fistulae in the hard and/or soft palate (evaluate for size, location, and patency); and
  • evidence of prior palatal or pharyngeal surgery (scarring, placement of sphincter or pharyngeal flap).
• For individuals with no history of cleft palate,
  • visually examine and palpate the soft palate—look for signs of possible submucous cleft palate, including
    • bony notch at the junction of the hard and soft palate (the SLP should also palpate the palate to detect the presence of a notch that might be felt but not visualized);
    • bluish line or translucent appearance down the midline of the palate (zona pellucida);
    • midline furrow or v-shaped elevation during phonation; and
    • bifid uvula
• Note the factors that might provide clues about etiology of VPD (e.g., symmetry of movement of soft palate during phonation).

• Precedes and determines the need for instrumental assessment
• Includes classification of speech sound errors; assessment of resonance and airflow; and correlating perceptual speech data with orofacial exam findings

See A Guide for Cleft Palate Speech Sampling [PDF] (adapted from Trost-Cardamone, 2013)

Speech Sound Production

• Differentiate speech sound error types across a variety of speech contexts. Error types include
  • obligatory articulation errors (those that are physically based/due to VPD or dental/occlusal differences);
  • compensatory articulation errors (including backed/retracted oral productions and learned nasal fricative patterns); and
  • developmental articulation errors and phonological errors (see ASHA's Practice Portal page, Speech Sound Disorders: Articulation and Phonology).
• Assess stimulability for compensatory errors and for developmental speech sound errors.
• Assess speech intelligibility/understandability and acceptability (see ASHA's Practice Portal page, Speech Sound Disorders: Articulation and Phonology, and Henningsson et al., 2008).

Resonance

• Assess for resonance deviations; listen for the following:
  • Hypernasality
    • Excessive nasal resonance enhancement on vowels, glides, liquids, and, in severe cases, voiced oral consonants.
  • Hyponasality
    • Too little or absent resonance enhancement on nasal consonants and adjacent vowels, especially /i/ and /u/.
    • Due to nasal cavity obstruction (e.g., enlarged adenoids, restricted pharyngeal cavity space due to maxillary retrusion).
  • Mixed resonance
    • Elements of both hypernasality and hyponasality.
  • Cul de sac resonance
    • A variation of hyponasality.
    • Sound resonates in the nasal, oral, or pharyngeal cavity but is "trapped" by some obstruction.
      • Nasals (/m/, /n/, and "ng") and nasalized sounds are "muffled" (due to anterior nasal obstruction).
      • Speech seems "mumbled" (e.g., due to small oral cavity).
      • Speech is described as "potato-in-the-mouth" (e.g., due to enlarged tonsils).

Nasal Airflow

• Use production of oral pressure consonants—including stops, fricatives, and affricates—to assess nasal airflow.
  • Listen for audible nasal air emission across multiple speaking contexts.
  • Determine whether nasal air emission is pervasive or phoneme specific.
  • Listen for presence of weak pressure or no plosive quality on oral pressure consonants (obligatory to VPD).

Low-Tech Procedures (Using Oral Pressure Consonants)

• Used secondarily to confirm or verify what clinician has heard.
• Sometimes used to check for (and rule in or out) inaudible nasal emission.
• Include the following:
  • Visual Procedures
    • Hold a mirror under nares to detect nasal air emission—look for fogging during production of phrases containing oral pressure consonants and no nasal consonants (e.g., "Pick a puppy").
    • Look for nasal grimace during speech that might coincide with nasal air emission.
  • Tactile Procedures
    • Feel the sides of the nose for vibration that may accompany perceived hypernasality.
  • Auditory Procedures
    • Alternately pinch and then release pressure on the nose (cul-de-sac test) while the child produces the same speech segment; listen for a resonance and/or pressure shift when nostrils are closed; VP valve dysfunction is signaled by cul-de-sac resonance and improved oral pressure with nose pinched.
    • Place one end of a straw or listening tube at nostril entrance and the other end to the examiner's ear during production of oral consonants; listen for sound/airflow exiting the nostril.

• Helps to explain perceptual speech findings with regard to VP function.
• Assists with planning of VP surgical or prosthetic intervention.
• Typically completed by an SLP affiliated with a cleft palate team.
• Recommended when the perceptual speech findings identify a resonance disorder or nasal air emission.
• Methods include
  • Direct Observation via Imaging Studies
    • Multiview videofluoroscopy — provides real-time x-ray video image of velopharyngeal function during speech from a variety of angles.
    • Nasopharyngoscopy — provides detailed video of the velopharynx during speech from above the velopharynx.
    • Lateral cephalogram — provides a static x-ray of the palate at rest and during phonation of /i/, / u/ or sustained oral /s/
  • Indirect Measures
    • Nasometry — measures nasalance, a ratio of acoustic energy from speaker's oral and nasal cavities; nasalance is reported to have a modest correlation with listener ratings of resonance.
    • Pressure-flow studies — measure oral and nasal pressure and nasal airflow; allow for indirect computation of VP orifice size during consonant production.

• Assess for voice quality and signs of vocal fold pathology (e.g., vocal nodules).
• May include
  • auditory-perceptual assessment;
  • instrumental assessment;
  • assessment of voice handicap; and
  • referral for ENT assessment.

For more information, see ASHA's Practice Portal page, Voice Disorders.

• Components will depend on the individual's age and linguistic stage.
• May include both standardized and nonstandardized assessments.

For more information, see the following ASHA resources:

• ASHA’s Practice Portal Page, Spoken Language Disorders
• ASHA’s Practice Portal Page, Written Language Disorders
• ASHA's resource on assessment tools, techniques, and data sources
• ASHA’s Practice Portal Page, Late Language Emergence
•  ASHA’s Practice Portal Page, Early Intervention

• Identification of
  • communication participation and activity (e.g., difficulty being understood; reduced participation in classroom activities);
  • facilitators (e.g., desire to interact with peers; supportive family and teachers); and
  • barriers (e.g., reluctance to initiate conversation with peers).

Note. VP = velopharyngeal; VPD = velopharyngeal dysfunction; ENT = ear, nose, and throat.

See Process Model for Assessing Speech, Resonance, and Language in Patients with Cleft and Craniofacial Anomalies [PDF] (Vallino-Napoli, 2004) for one example of an assessment decision-making flow chart.

References

Hall, M. J., Gibson, B. J., James, A., & Rodd, H. D. (2013). Children's and adolescents' perspectives on cleft lip and/or palate. The Cleft Palate-Craniofacial Journal, 50, e18–e26. 

Henningsson, G., Kuehn, D. P., Sell, D., Sweeney, T., Trost-Cardamone, J. E., & Whitehill, T. (2008). Universal parameters for reporting speech outcomes in individuals with cleft palate. The Cleft Palate-Craniofacial Journal, 45, 1–14.

Trost-Cardamone, J. (2013). Cleft palate speech: A comprehensive 2-part set. Rockville, MD: American Speech-Language-Hearing Association.

Vallino-Napoli, L. (2004). Assessing communication in cleft and craniofacial disorders: A process model for the practitioner. Perspectives on Speech Science and Orofacial Disorders, 14, 9–16.