1. What are the 7 cosmetic goals of primary surgery on the primary palate?
    • Vermillion Border into line
    • Cupid's Bow preserved
    • Mucous Membrane accurate union
    • Nostril symmetry
    • Lip fullness
    • Tissue discard minimal
    • Scar minimization/shrinkage
  2. When is surgery for the primary surgery of primary palate timed?
    • As early as few weeks to 3 months old
    • Medically stable
  3. What is the "Rule of 10s?"
    • 10 weeks of age
    • 10 lb weight
    • 10 grams or higher hemoglobin count (RBC)
    • 10,000 or less White Blood Cell count
  4. What's the rationale for doing the primary surgery early?
    • Trauma minimal for parents
    • Feeding problems reduced
    • Migration of premaxilla minimized
  5. What's the rationale for doing primary surgery later?
    • Tissue (more available)
    • Acceptance of parents
    • Concomitant problems present
  6. What are 4 primary surgeries of the primary palate?
    • Rose-Thompson
    • Triangular Flap
    • Rotation Advancement/Z-plasty
    • Lip Adhesion
  7. Image Upload 1
    • Rose Thompson
    • Straight Line procedure
  8. What primary surgery of the primary palate is reserved for minimal clefts and is a straight line procedure?
  9. The drawbacks of this surgery are that it sacrifices too much tissue (short lip) and that it destroys cupid's bow?
  10. Image Upload 2
    Triangular Flap
  11. What primary surgery of the primary palate is reserved for more extensive clefts (prime)?
    Triangular Flap
  12. The advantages of this surgery are that it wastes little tissue, produces full lip, and has a natural cupid's bow.
    Triangular Flap
  13. The disadvantage of this surgery is that it creates an elongated lip on cleft side.
    Triangular Flap
  14. Image Upload 3
    • Rotation Advancement
    • Zplasty
  15. What primary surgery of the primary palate does the scar line up along the philtral ridge from the base of columella?
    • Rotation Advancement
    • Z-plasty
  16. The advantages of this surgery are flexible lips and procedure, and easier revision.
    • Rotation Advancement
    • Z-plasty
  17. Image Upload 4
    Lip Adhesion
  18. What primary surgery of the primary palate creates 2 raw surfaces on each side of the cleft for better preliminary alignment prior to a later definitive lip repair?
    Lip Adhesion
  19. What are the goals of the primary surgery of the secondary palate?
    • Velar Mechanism that's functional
    • Maxillo-facial growth (to avoid dish-face)
  20. How is success measured for a functional velar mechanism?
    Speech accuracy
  21. What's the rationale for secondary palate surgery done early?
    Functional Velum (so that at 18 mos. they can develop S-L)
  22. What's the rationale for secondary palate surgery done later?
    • Growth plates could be damaged
    • Dish-face
  23. What are 7 subgoals of secondary palate surgery?
    • Feeding easier
    • Oral/nasal cavities separate for speech/swallowing
    • Eustachian tube function improved (prevents OM)
    • Upper Respiratory Infections reduced
    • Growth of maxillo-facial complex improved
    • Dentition functionality
    • Palatal Vault normal
  24. When is the primary surgery of the secondary palate timed?
    Early as 9-12 months to 2 years old
  25. What are the 2 most common primary surgeries of the secondary palate?
    • Modified Von Langenbeck
    • V-Y Retroposition/Veau-Wardill/W-Y
  26. Image Upload 5
    Von Langenbeck
  27. Which primary surgery of the secondary palate makes lateral incision along alveolar ridges, edges are pared, creates 2 bi-pedicled flaps,and tissue freed up so it can be slid toward midline and sutured to close cleft? It also leaves denuded bone where incisions made that will later fill with granulation tissue forming a scar that appears white.
    Modified Von Langenbeck
  28. The advantages of this surgery are that it emphasizes preservation of blood supply and growth retardation prevented by mucosa being sutured off?
  29. The disadvantage of this surgery is limited length of velum.
    Modified Von Langenbeck
  30. Image Upload 6
    V-Y Retroposition
  31. Which primary surgery of the secondary palate is more common in the U.K. and prepares 2 uni-pedicled flaps leaving denuded bone?
    V-Y Retroposition/Veau-Wardill/W-Y
  32. The advantage to this surgery is that there's more potential for greater length of velum.
    V-Y Retroposition/Veau-Wardill/W-Y
  33. Image Upload 7
    Scheckendick Veloplasty
  34. What's the primary veloplasty surgery?
  35. Which surgery's goal is to recreate the levator sling by closing soft palate at early age and waits to repair hard palate until adolescence while pt wears a prosthetic device in hard palate to inhibit growth retardation of the maxillo-facial complex?
    • Scheckendick
    • Primary Veloplasty
  36. What are 2 supplemental procedures to augment primary procedures in order to provide a better foundation?
    • Vomer Flap
    • Bone Graft
  37. Image Upload 8
    Vomer Flap
  38. Supplemental palatoplasty surgery that uses the mucoperiosteal tissue of the vomer to cover a unilateral or bilateral cleft palate. This procedure can be used to reconstruct the nasal or oral surfaces by either raising the vomer or creating a flap. Drawbridge closes the gap
    Vomer flap
  39. Oral-Nasal Fistula can occur if this supplemental procedure is not done; soft tissue breaks down and hole results. Borrowing site usually from rip or hip.
    Bone graft
  40. What's the goal of secondary procedures of the secondary palate?
    • Velopharyngeal Sufficiency achievement
    • complements the primary procedure
  41. What secondary procedure of the secondary palate creates a flap of muscle tissue bulge into the posterior pharyngeal wall in the hope that the bulge will become dynamic (like manmade Passavant's pad)?
  42. What secondary procedure of the secondary palate implants some kind of inert/stable substance that won't do anything but will create a bulge that will hopefully make the distancein closing the gap. Silicon, teflon, collagen, and cartilage have been used for this.
    Pharyngeal Implant
  43. What are the problems that can occur with pharyngeal implants?
    • Migration
    • begins to slip into a wrong position (oyster) that's not beneficial
    • Teflon is carcinogenic and can no longer be put in a human's body
  44. What is the most common secondary procedure of the secondary palate?
    Pharyngeal Flap
  45. What's the biggest drawback of the early versions of pharyngeal flaps?
    • Shrinkage
    • surgeon will now make flap bigger than needed
    • child will be hyponasal for first 3 wks until swelling goes down
  46. Most common pharyngeal flap where base is above the flap itself. If there's active muscle tissue it will elevate velum.
    Superiorly based pharyngeal flap
  47. Pharyngeal flap where base is below the flap itself. Does not aid in velar closure but will aid in lateral wall movement.
    Inferiorly based pharyngeal flap
  48. When will a pharyngeal flap surgery be done?
    • By age 2 (early as 12 mos) to help with speech
    • at age 2 a phonetic inventory on sounds can be done to check for nasality
    • Sometimes they wait until 6-12 years old
  49. Image Upload 9
    • Palatal obturator
    • Speech bulb
  50. What's the best prosthesis for pts whom the soft palate is mobile but too short to adquately close the VP port completely? Provides surface for pharyngeal walls to squeeze against providing VP valving. May provide replacements for teeth.
    Speech Bulb Palatal Obturator
  51. Why are 4 reasons prosthetics may be used?
    • Anesthesia contraindicated due to serious health cond.
    • Insufficient tissue to reconstruct palate surgically
    • Supplement unsuccessful primary surgery
    • During waiting period prior to surgery
  52. Image Upload 10
    Palatal Lift
  53. What type of prosthetic is used when velum is intact but has inadequate movement. This device lifts velum into a position so that when it moves it will come into contact with pharyngeal wall. Velum crutch.
    Palatal Lift
  54. What are the advantages of using cephalometerics?
    • Radiation limited to one shot
    • Process easy
    • Widely available
  55. What are the disadvantages of using cephalometrics?
    • Static speech not dynamic
    • Masking problem--may not pick up the gap due to summation of tissues
  56. X-ray slices may detect what the masking of basic radiograph didn't but still requires static speech.
    Computerized Axial Tomography (CAT scans)
  57. What are the advantages of using videofluoroscopy?
    • Dynamic connected speech=better VP function analysis
    • Longer utterance
    • High speed film
    • Frame-by-frame analysis can be done
  58. What are the disadvantages of using videofluoroscopy?
    • Radiation exposure time (continuous)
    • Limited to one view
    • Not widely available
    • Complex/Expensive
  59. What's the name of the original oral parendoscope that was not useful because of rigidity pts couldn't talk, gag, and burnt from hot light bulb?
  60. What are the advantages of using fiberoptic endoscopy?
    • No radiation (light retrieves image)
    • Dynamic speech
    • Visualization of lateral wall/velar movements
    • "Live"/recorded structure visualization
  61. What are the disadvantages of using oral fiberoptic endoscopy?
    • Speech interferement
    • Gag reflex a problem for some
  62. What's the disadvantage of using nasal fiberoptic endoscopy?
    • Nasal obstruction
    • deviated septum or overgrown turbinates
    • Lateral wall movements not seen as easy
  63. What instrument measures the amount of intraoral air pressure that can be exerted/generated by an individual and is no longer used?
    Oral manometer
  64. What instrument uses a coil with an arrow attached sealed in a case to measure unit of intraoral air pressure by a person blowing through a tube, air compresses coil and the attached arrow moves to point to the numeric unit of air pressure? (An average of 3 measurements each w/ nares open/closed)
    Oral Manometer
  65. If person had a VPI, would they be most successful with nares open or closed when using oral manometer?
  66. What's the advantages of using an oral manometer?
    • Low-tech
    • Easy to use
  67. What are the disadvantages of using an oral manometer?
    • Non-speech activity/blowing
    • Reliability poor due to low effort/pain in Eustachian
  68. What's the best instrumentation to detect VPI by translating fluctuations of air pressure into elecrical signals?
    Pressure Flow Technique/Pressure Transducer
  69. What instrument has one tube go in the mouth for oral pressure and two in the nose one with a nasal olive that measures nasal pressure during nasal sounds and another that is directed into a heated flowmeter that detects nasal emissions that cool a wire to increase electrical signal.
    Pressure Transducer/Pressure Flow Technique
  70. The pressure flow technique correlates measures of what?
    • Nasal airflows vs.
    • Oral & Nasal air pressure variations
  71. If there's a big VPI leak, it'll take __________ to get nasal emission.
    Less Oral Pressure
  72. What are the advantages of using Pressure Flow Technique?
    • Very small leaks can be detected
    • Dynamic speech is used (contrasts low/high pressure)
  73. What are the disadvantages of using Pressure Flow Technique?
    • Location of leak cannot be determined
    • Complex/Expensive
  74. VPI rating of less than 5mm2
    No effect
  75. VPI rating of less than 5-10 mm2
    Borderline/Inconsistent effects
  76. VPI rating of 10-20 mm2
    Marginal VPI
  77. VPI rating of greater than 5-10 mm2
    • Consistent VPI
    • Surgery needed
  78. This instrument measures resonance imbalance through acoustic energy by monitoring VP behavior during speech using microphones on a plate under nose, signals fed to computer creates a ratio of nasal acoustic energy divided by nasal acoustic energy plus oral acoustic energy.
  79. Resonance which is the percent of all acoustic energy that is emanating through the nasal cavity.
  80. What are the advantages of using a nasometer?
    • Affordable ($3500)
    • Dynamic speech
    • Simple technology
  81. What are the disadvantages of using a nasometer?
    • VPI is only inferred
    • No Nasal Emission information
  82. What type of articulation errors are common in preschool?
  83. What type of articulation errors are common in school-age?
    • Substitutions
    • especially glottal stops
  84. What type of articulation errors are common in adolescence/adults?
    • Distortions
    • nasal emissions
  85. List the most to least difficult manner of production for speakers with cleft palate.
    • Sibilants
    • Affricates
    • Fricatives
    • Plosives
    • Glides
    • Nasals
  86. What's the most difficult place of articulation for speakers with cleft palate?
    Front of mouth sounds
  87. In what sounds is the glottis closed half the time so air pressure drops making them less difficult?
  88. Regarding context, __________ are more difficult than single phonemes.
  89. Better speech is associated with earlier surgery, what would be the main reason surgery was delayed?
    Concomitant medical problems
  90. What type of cleft will individuals most likely have better speech?
    Primary cleft palate
  91. If person that has cleft has nasal obstruction, why will their speech sound better?
    • Path of least resistance-obstruction allows less air in nasal cavity
    • Increases nasal impedance
  92. Why does dentition/occlusion not affect speech much?
    Tongue can adapt easily
  93. Consistency is the _________ of specific consonant productions and the consistency of those productions.
  94. What is the most typical specific articualtion error in cleft palate speakers?
    • Nasal Emission due to hypernasality
    • airflow/nasal turbulence/snort
    • audible or inaudible
  95. What test is used to evaluate phonetic context and tests consistency of phonemes production?
    McDonald Deep Test of Articulation
  96. Which instrumentation/procedure is best for measuring airflow (nasal emission)?
    Pressure Flow Technique (nasal olives)
  97. NE/s
    Nasal Emission almost obliterates /s/
  98. Squiggly above /s/ with two dots
    Nasal emission w/ Nasality
  99. Double tildy above /s/
    Snort or turbulent (twice as bad)
  100. Tildy with line through it
  101. Nasal emission ________ is the best/direct/physical evidence of a leak.
    • Distortion
    • distorts overall sound
    • this isn't learned (either you have deficiency or you don't)
  102. Compensatory substitution that is done to build up pressure right below port so won't have to rely on velum ("bottle"; "Lawton")
    Glottal Stop
  103. Glottal stop but moving the point of restriction up against posterior pharyngeal wall.
    Pharyngeal stop
  104. Compensatory strategy that presses tongue to back of pharynx; pressure is below velum (cough up hairball sound)
    Pharyngeal fricative
  105. Compensatory substitution sounds like a "German /r/" or "Arabic" sound. (Curvy X)
    Velar Fricative substitution
  106. Compensation by valving with the nares; this is a learned behavior won't go away just because cleft is repaired.
    Nares constriction
  107. What's the typical voice quality of cleft palate speakers?
  108. Often cleft palate speakers exhibit ________ pitch in their voice.
  109. Hypernasality deals with __________ not airflow.
    • Acoustics
    • Resonance
  110. Explain cul-de-sac resonance.
    • Front end blocked off
    • Back end accessible
    • Hollow/"jug band" music
  111. How does having cleft palate possibly affect language?
    • Syndromes contribute to many of child's problems
    • Hearing/otitis media
    • Hospitalization/less language rich experience
    • Parent maladjustment/may not get out in public
  112. It all depends on how the child was raised...
    Social/Psychological problems
  113. What evaluation test focuses on * items (sibilants, fricatives...high pressure consonants); could do same thing with picking these out on the Goldman Fristoe.
    • Iowa Pressure Articulation Test (IPAT)
    • Templin-Darley Test of Articulation
  114. What tests for error patterns and is organized in columns with headings such as nasal emission, velar fricative, nares constriction, pharyngeal fricative)?
    Bzock Error Pattern Test
  115. This test is not particularly useful because cleft speech errors are in articulation not phonological (linguistic).
    Kahn-Lewis Phonological process
  116. In this test the child says a word such as "beat" over and over with and without nares closed.
    • Cul-de-sac hypernasality test
    • if cul-de-sac resonance the word will sound changed
  117. What's the treatment or nasal emission that is consistent?
  118. This program affects hypernasality: syllable combinations starting with low oral impedance and then move up the hierarchy to plosives.
    Program for Elimination of Hypernasality in Phonetic Contexts
  119. Cleft speech management is based on successive _________.
  120. What are 4 steps to establish correct articulatory placement in response to compensatory errors?
    • Pharyngeal flap often gives some instantaneous results
    • Greater jaw/oral opening during vowels, glides & liquids decreasing oral impedance
    • Lighter articulatory contacts (easy speech) reduces intraoral peak air pressures
    • Slow rate of speech creates longer transitions bet/C-V giving velum a beter chance to make contact with pharyngeal wall.
  121. Oral calisthenics/blowing exercises are supposed to help with nasal emission but doesn't really. How can it be used?
    • Demonstrates when air comes out mouth vs. air coming out nose.
    • Demo this then move to speech
  122. What are 3 forms of biofeedback discussed in class?
    • Endoscopy (oral/nasal)
    • Nasometer
    • Seescape
  123. Biofeedback technique using fiberoptic technology so that they can learn to control muscles when they see the effects visually on monitor.
  124. Using this biofeedback device with plate and 2 microphones games can be played. (Birdie in the sky)
  125. This biofeedback tool has a clear vertical tube with a thinner flexible tube that goes in nose. If the plug goes up and down it's an "oops" if it doesn't move, they've got it. Helps post flap surgery to teach them how to use it.
  126. What are 10 people that may serve on a cleft palate team?
    • Pediatrician
    • Otolaryngologist (ORL)
    • Plastic Surgeon
    • Prosthodontist
    • General Dentist
    • Audiologist
    • SLP
    • Psychologist
    • Social Worker
    • Parent
  127. What are the advantages of a cleft palate team?
    • Coordinated/comprehensive care
    • Travel/appointments minimized
  128. What's a disadvantage of a cleft palate team?
    • Family has difficulty relating to all professionals at once
    • Social worker or experienced parent can help offset
  129. What are 5 roles of the SLP?
    • Evaluate artic/resonance when considering secondary proc.
    • Avoid developing "golden ear" syndrome
    • Predict speech expectations (adenoids)
    • Trial management/decision making
    • Post-op evals (hoping for hyponasality)
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