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Communication Disorders
Communication Disorders

Plastic Surgery Cleft Palate/Craniofacial/VPI Clinics

The Speech-Language Pathologists in the Plastic Surgery Program at SickKids are an integral part of a multidisciplinary team that provides assessment and management of children with cleft lip and/or palate, craniofacial conditions, and velopharyngeal insufficiency (VPI).  

How to make a referral to the Cleft Palate/Craniofacial Programs:  

How to make a referral to the VPI Clinic:  

  • The VPI clinic at SickKids accepts referrals from Physicians and Speech-Language Pathologists for children under 18 years of age who present with hypernasal speech of unknown etiology.
  • Referrals can be sent via our online Ambulatory Referral Management System (ARMs) or by faxing a referral form (available in PDF format) to 416-813-6487.  

What is hypernasal speech (velopharyngeal dysfunction):

Hypernasal speech (resonance) is the sound that results from too much air escaping through the nose while talking.  To prevent the air from passing through the nose while talking, the soft palate (velum) must touch the back of the throat.  If there is not a complete seal, air can leak into the nose when it should not and this results in nasal-sounding speech (hypernasality) and velopharyngeal dysfunction.  In English, all sounds with the exception of nasals (m, n, ng) require velopharyngeal closure.

What are some common causes of hypernasal speech:

Hypernasal speech may be caused by structural problems such as cleft palate, a palate that is too short, or an inability to move the muscles involved with closing the soft palate against the back of the throat.  

What is hyponasal speech:

Hyponasal speech (resonance) is the sound that results when not enough air/sound passes into the nose during the production of nasal sounds (m, n, ng).  This results in the person sounding like they have a cold or stuffy nose.  Patients with hyponasal speech/resonance should be referred to an Otolaryngologist for an assessment to determine the cause of the problem.

Children followed through the Cleft Palate Program

The Speech-Language Pathologist monitors speech, language and resonance at different time points in your child’s development.  Throughout the course of your child’s development, the Speech-Language Pathologist interacts with various disciplines to determine the relationship between speech-language development and other factors (e.g., hearing, dentition, learning).  Together, our goal is to ensure that your child is maximizing his/her potential for developing good communication skills.

Post Cleft Palate Repair

  • Approximately 6-8 weeks after your child’s cleft palate repair, the following will be addressed:
    taking a detailed history
  • Observing the child play and listening to his/her vocalizations
  • Asking questions regarding your child’s communication skills
  • Providing you with written material explaining what you can do to stimulate your child’s oral-motor and speech-language development
  • Determining whether a referral for further speech-language intervention is necessary
  • Determining whether your child needs to be seen for monitoring prior to the scheduled 3-year old evaluation (Speech-Hearing-Dental Assessment)

Three Year Speech-Hearing-Dental (SHD) Assessment

At this appointment, the Speech-Language Pathologist will look at:

  • Updated history
  • Examination of the oral structures for speech (e.g., lips, tongue, palate)
  • How your child produces speech sounds (articulation testing)
  • How well your child understands language (receptive language)
  • How well your child’s vocabulary and grammar are developing (expressive language)
  • The quality of your child’s resonance (nasality)
  • Whether more direct speech-language therapy is needed
  • Whether your child needs to be seen for monitoring prior to the scheduled 5-year Team Staffing

Five Year Team Staffing Assessment:

The Five Year Team Staffing Assessment is similar to the SHD Assessment.  However, the emphasis at this stage is to determine if the palate is working properly.  The Speech-Language Pathologist will listen to your child’s speech and a computer test called the Nasometer will be used to document the amount of sound coming from your child’s nose and mouth.  

If the child’s speech appears to be too nasal, then further testing (e.g., Nasopharyngoscopy; Multiview Videofluoroscopy) may be recommended.  If these tests determine that your child’s palate is not working properly and speech therapy will not correct the problem, your child may require further surgery to improve speech.  The type of surgery recommended (palatoplasty, pharyngoplasty) is based on all the information obtained in consultation with your child’s Plastic Surgeon.  After surgery your child will be seen 6-8 weeks post-operatively by their Plastic Surgeon and by a Speech Language Pathologist in order to monitor progress and to determine if further speech therapy is needed. Your child will continue to be routinely monitored to ensure they are achieving the best possible speech and resonance quality. For selected children who may not be a surgical candidate, a dental speech appliance (palatal obturator/lift) may be recommended.

Cleft Lip Only

For the most part, children with clefts involving only the lip and alveolar process (gum ridge) do not have significant speech problems.  The likelihood of your child having a speech or language problem is similar to children who do not have a cleft lip.  However for some children, there may be significant abnormalities in the lips, teeth and jaw relationship that result in problems saying certain speech sounds (e.g., “s”).  In general, the more severe the abnormality, the greater the likelihood of speech difficulties.

Teen Years

At this stage, the Speech-Language Pathologist’s role is to determine if any further services are required and to consult with the rest of the team regarding management.  For some teenagers, the orthodontist and plastic surgeon may be recommending movement of the jaws in order to properly align them (Orthognathic Surgery).  If the upper jaw is moved forward, it may be more difficult for the soft palate to contact the back of the throat during speech.  Individuals with cleft palate who already have nasal-sounding speech or who have inconsistent contact are at greater risk for sounding more nasal following jaw surgery.  Should concerns with increased nasality occur following jaw surgery, further testing (Nasometry, Nasopharyngoscopy) will be done to plan for further management. 

Children followed through the Craniofacial Program

If there are concerns about your child’s speech, language, resonance or voice; the Craniofacial Program will make arrangements for your child to be seen by a Speech Language Pathologist on the team.

Children referred to the VPI Clinic

Your child will be seen for an initial assessment. At that time an evaluation of your child’s resonance will typically include:

  • Review of concerns and medical history
  • Perceptual evaluation of resonance quality
  • Screening of articulation and language skills (if appropriate)
  • Examination of the oral structures
  • Acoustic analysis of resonance (Nasometry)

Based on results of the initial assessment, the following may be recommended:

Once the Speech Language Pathologist has all the information needed, recommendations will be made regarding management options (speech therapy, surgery, dental appliances) and initiation of referrals to appropriate professionals.

Before your appointment

Before your appointment you may receive an information package in the mail or by email. Please complete the parent questionnaire and mail or fax the forms back to the clinic as soon as possible. Please attach any relevant speech and language, educational or medical  reports. If you cannot return the questionnaire prior to your appointment, please bring it at the time of your child’s assessment.