Speech

Children with cleft palate have a tendency toward a speech problem called velopharyngeal insuffiencey (VPI). VPI is caused by the inability of the muscles of the soft palate to close off the airflow from the mouth to the nose, when certain sounds are made. Patients with this problem sound hyper-nasal and often have air escaping (nasal emissions) out her nose during speech when they should not. Nationally, this problem occurs in 1/20 patients with cleft palate. It almost never occurs in a patient with an isolated cleft lip. (VPI picture)

In many cases, this problem can be corrected non-surgically with adequate speech therapy. Our unit provides state of the art speech evaluation beginning at age 1. Our speech therapists evaluate the patient prior to palate closure and help decide on the timing of closure based on the amount of babbling and word formation the child expresses. Then at age 3 , the child is reevaluated for signs of VPI. If VPI is detected, speech therapy is initiated early. In cases where intensive speech therapy is not effective, surgical correction of VPI is initiated.

When surgery is considered, a complete speech and ENT evaluation is performed. Diagnostic videofluoroscopy and nasoendoscopy are performed in order to identify the type of problem present during soft palate closure. The ENT physician on the team will also evaluate the need for tonsil and adenoid removal prior to any surgical speech therapy. Based on these finding, specific surgical procedures are performed in order to try and correct the VPI. This typically requires an overnight stay in the hospital followed by continued speech therapy post operatively to maximize the result.

The surgeries most commonly performed are the pharyngeal flap and the sphincter pharyngoplasty. However, other surgical procedures are available and Dr's Stelnicki will discuss these options with you when appropriate. In addition, some patients are not good surgical candidates. In these patients, non-surgical treatments of VPI such as palatal lift appliances or speech bulbs are offered to the patient. These devices are made in conjunction with a speech therapist, ENT, and pediatric dentist for proper fit and function.

It is also important to understand that children with cleft palate frequently have delayed language development. However, following palate repair, they rapidly "catch up" and by 4-5 years of age should be on par with any child, provided the soft palate moves normally.

Hearing

Because of abnormal drainage of the ear canal (eustachian tubes) in patients with cleft palate, fluid frequently collects behind the eardrums. In some patients, this leads to an excessive amount of ear infections. In others, this can cause a significant decrease in conductive hearing. An audiology test and ear exam will assess the need for myringotomy tube placement in the ears. The test most frequently performed in infants is an ABR (auditory brainstem response). If the child fails this test, then more in depth testing is needed to determine the need for tube placement. Hearing loss is most frequently due to fluid on the middle ear which decreases the ability of the eardrum to vibrate. This is a conductive hearing loss. Occasionally, there can be a problem with the inner ear which inhibits the transmission of nerve signals to the brain. This is a sensineural healing loss. Only the conductive hearing loss can be treated with ear tubes. Other hearing tests such as behavior audiometry, impedance audiometry, and play audiometry can be used to further define hearing loss in children, depending on the age of the child. our team uses a certified audiologist as part of the Joe DiMaggio cleft and craniofacial center to determine the proper test for your child.

If this surgery is needed, it will unblock the fluid filled eardrums which can hamper speech development. We therefore recommend a hearing test in all patients. The time of the tube placement is either coincident with the closure of the lip or palate, depending on the patients needs. This surgery not only improves hearing, but also aids in the development of proper speech.

Palatal Fistula

This is a rare sequelae of cleft palate repair. A fistula is an abnormal connection between the mouth and the nose. They are usually very small, but can be large on occasion. Fistula can occur in any location, extending from the gum to the end of the soft palate. The most common location is at the junction of the hard and soft palate. When a patient has a fistula present, the size and location of the fistula are carefully evaluated. There are hundreds of methods for closing fistulae. Dr's Stelnicki will discuss the best possible options with you and decide which surgical methods best fits your needs and has the highest likelihood of successful closing the hole.

Occasionally, small fistulae open up and become larger during orthodontic expansion of the palate. When this occurs, these fistula are closed only after all orthodontic expansion is complete. These closures can occasionally be combined with alveolar bone grafting if orthodontic alignment is in process. Careful coordination between the surgeon and orthodontist is needed to optimize the result. Dr's Stelnicki works closely with several very experienced orthodontists who can help achieve this goal.

Orthodontics, Dentistry, and Orthognathic Surgery


All orthodontic and dental treatment will be provided through the skilled orthodontic teaching staff at NOVA Southeastern University School of Dentistry. Patients with clefts have a variety of orthodontic problems. They can have an alveolar cleft in the gum line that needs to be closed. They can have missing, impacted or abnormal teeth that which develop along the cleft. They can also have abnormal growth of their upper jaw.

Careful orthodontic and dental evaluation is required to correct these problems throughout a child's development. As a infant, the pediatric dentist will be involved in making alveolar molding plates and the nasoalveolar molding device for the cleft nose. The pediatric dentist will also care for any abnormally developing teeth, and make recommendations about extraction when necessary.

At age 7-8, the orthodontist will determine the need for dental extractions and alveolar cleft closure. At this time, the orthodontist may also begin expanding the palate in order to correct cross bites, that cause the teeth not to fit properly together. At this age, the orthodontist will also work with the speech therapist, when needed, to make speech bulbs. They also work with a prosthodontist to place artificial teeth and bridges in areas wear teeth are missing.

In the teen years, orthodontics will be required in order to normalize dental relationships. They may include standard orthodontics, maxillary expansion, anterior pull headgear, or even preoperative orthodontics to get a patient ready for upper jaw surgery.

If upper jaw surgery is required, the orthodontist will work closely with the craniomaxillofacial surgeon to plan the operation so that after the surgery, excellent dental alignment will be achieved. Our group offers all surgical options ranging from standard orthognathic surgery to distraction osteogenesis of the care of the deficient maxilla. In addition, we are the leaders in the development of absorbable distraction osteogenesis technologies.

The growth of all our patients is meticulously documented. Any problems with growth are picked upon dental study models and well as cephalograms or CT scans. These objective measures of growth re compared to normative data in order to properly correct the anomaly. Virtual reality surgery is offered to those patients who require complex reconstruction of their facial skeleton such s patients with rare Tessier craniofacial cleft, Treacher Collins syndrome, craniofacial microsomia, a variety of craniosynostosis syndromes, etc.