1. History of speech therapy after cleft palate surgery
In 1948, Norway established the world’s first cleft lip and palate treatment TEAM, the Oslo team, which first proposed the centering, standardization, diversification, sequencing, long-term and continuity of cleft lip and palate treatment, and developed the Oslo treatment plan. With the development of science and technology, the methods and means of speech therapy have been constantly updated and enriched, and have been expanded to include all treatments that promote speech rehabilitation except surgery. With the continuous improvement of the sequential treatment system, the speech function of children with cleft palate has been greatly improved. In Japan, the rate of speech improvement after cleft palate surgery has increased from 65% to 90% in the past 40 years, thanks not only to the development of anesthesia and surgical techniques, but also to active postoperative speech therapy.
In China, post-operative speech therapy for cleft palate patients has been pioneered in a few large dental hospitals since the 1980s. Since there is no specialization in speech pathology in China, speech therapy has been performed by oral and maxillofacial surgeons. Since the 1990s, some hospitals in Beijing, Shanghai and Guangzhou have set up special cleft lip and palate treatment centers and established initial sequential treatment centers. treatment centers and established a preliminary sequential treatment program. A long-term review system has been established for post-operative patients, and doctors engaged in phonological pathology research are working on phonological correction. Scholars have been exploring the methods of Chinese speech correction from the pronunciation mechanism according to the specific situation of Chinese speech, and a lot of related literature has been published, which have accumulated valuable clinical experience for the speech correction work in China.
Currently, most of the post-operative speech correction for cleft palate in China follows the principle of behavioral therapy. Behavioral therapy focuses on observable external behaviors and follows specific treatment steps designed to improve non-functional or non-adaptive psychological behaviors. Currently, the principles of behavioral therapy are mostly applied in post-operative speech therapy for cleft palate in China. This has better results for some patients, especially for younger patients aged 4 to 5 years. For schoolchildren over 6 years old, patients do not always have the ability to self-reflect on misconfigured sounds because of the complex and not easily observed articulatory movements. Or, although they can introspect, they cannot imitate the correct constructions. To address this problem, we use cognitive-behavioral game therapy. This treatment uses games as a vehicle for verbal and nonverbal communication with the patient using cognitive and behavioral oriented intervention techniques.
2. Diagnosis of dysarthria after cleft palate surgery
In general, children’s speech development ends around the age of 4 years. In addition, children over the age of 4 years are relatively easier to communicate, resulting in more accurate findings. Children with cleft palate should have successful surgery, no palatal fistula or short tongue tie, and exclude pharyngeal disorders such as adenoid hyperplasia. Also, neuropsychiatric disorders, hearing impairment, and mental retardation should be ruled out. Diagnostic language: Mandarin Chinese.
2.1 Hearing screening
Among children with cleft palate, 80% suffer from different degrees of otitis media, and some of them already have conduction deafness. Because middle ear disease makes patients unable to perceive normal speech, speech development is inevitably delayed, which will greatly reduce the effect of speech therapy, therefore, early intervention for hearing problems of children will be an important part of sequential therapy. Not only should early intervention be performed preoperatively, but long-term monitoring of the child’s hearing should also be performed during speech therapy to ensure the reliability of speech therapy. Some even believe that tympanic ventricular placement should be a routine intervention for children with cleft palate. Because of its complications, it has been suggested that long-term hearing aid wear not only avoids surgical complications, but also restores hearing.
2.2 Palatopharyngeal closure function test
The main goal of our surgery is to resolve the structural abnormality of incomplete palatopharyngeal closure in children with cleft palate, and after the initial cleft palate repair surgery, 20-30% of patients still have varying degrees of incomplete palatopharyngeal closure, resulting in nasal leakage, excessive nasal sounds and secondary compensatory dysphonia. It is usually believed that mild VPI and marginal palatopharyngeal closure can be treated by blowing training to promote palatopharyngeal closure function without surgery, while for more severe VPI, surgical treatment is required before speech training. Some scholars also believe that for younger VPI patients, they can wear a voice correction device first, together with voice training, which can correct the bad pronunciation habits at an early stage and can create good conditions for the second-stage surgery and greatly improve the success rate of the second-stage surgery.
There are many methods of palatopharyngeal closure function examination, which should be used in combination to achieve a variety of examination requirements such as qualitative, quantitative and visual. Our commonly used examination methods are.
Fogoscopy. Having the child pronounce /i/ and observing the nostril water vapor with a fogoscope can make a preliminary determination of nasal leakage.
Lateral palatopharyngeal film examination. Two lateral palatopharyngeal films should be taken, one for the normal cephalometric lateral film and the other for the cephalometric lateral film during the /i/ sound. The lingual position, posterior pharyngeal wall motion and soft palate motion of these two films are compared to determine whether the child has palatopharyngeal closure insufficiency on the one hand, and the degree of palatopharyngeal closure insufficiency on the other hand, so as to provide a basis for palatopharyngeal function correction.
Nasopharyngeal fiberoptic examination. Nasopharyngeal fiberscopy can visually observe the intensity and symmetry of the palatopharyngeal movement of the child at rest and during articulatory movements, and provide a basis for the design of functional palatopharyngeal correction, especially pharyngoplasty.
2.3 Physician’s hearing
The physician’s evaluation is a subjective examination. The physician should be familiar with Mandarin pronunciation and have a thorough understanding of the phonological position and articulatory movements of each phoneme. Usually, the physician will compose each phoneme into words and short sentences with things and actions that children can easily understand, and use the reading method to examine the child’s pronunciation, so as to grasp the characteristics of the child’s dysarthria. In order to check the characteristics of dysarthria of the child more accurately, audio recording and computerized speech analysis should also be performed. For this purpose, firstly, we should select suitable recording materials and record the vowel and consonant phonemes of the child. Two or more physicians should be available to perform the audio recording to eliminate subjective errors of the physicians.
3. Treatment of dysarthria after cleft palate surgery
Although speech therapy cannot correct palatopharyngeal closure insufficiency, the compensatory poor articulatory habits secondary to VPI can be overcome by speech therapy, and the abnormal facial expressions produced by patients to reduce nasal leakage can also be corrected by speech training. In patients with incomplete palatopharyngeal closure of cleft palate, the motor function of the lateral pharyngeal wall is often weak. After surgery, corresponding voice training methods are needed to increase the motor function of the lateral pharyngeal wall to obtain stable palatopharyngeal closure. Chen Yiyang, Department of Stomatology, Guangzhou Women’s and Children’s Medical Center
3.1 Postoperative palatopharyngeal closure function training
After cleft palate surgery, due to the scar caused by the surgical trauma and the palatal muscles still cannot reach normal motility after reconstruction, patients can be allowed to perform functional exercises for palatopharyngeal closure function in the first month after surgery. ①Promote scar softening by massaging the surgical scar area to improve palatal muscle perception and motor function. ②The blowing training can increase the pressure in the oral cavity, improve the patient’s palatopharyngeal closure function, and reduce the degree of nasal voice. In 1997, some scholars used nasopharyngeal fiberscope to perform visual feedback training on 17 postoperative cleft palate patients, and the results showed that the motor motility of the lateral pharyngeal wall muscles in the subject group was significantly improved, which affirmed the efficacy of nasopharyngeal fiberscope The efficacy of nasopharyngeal fiberscope in biofeedback treatment was confirmed. However, nasopharyngeal fibroscopy has not been performed clinically because it is an invasive instrument and has an effect on the patient’s articulation. Some people display the nasopharyngometer values in graphic and data form so that patients can analyze their articulation from the graph and numerical changes on the monitor and practice keeping the numerical form or graph within a certain range during articulation to improve palatopharyngeal closure and improve articulation skills. The study confirmed that the nasopharyngometer is not only very sensitive and reliable in the diagnosis of excessive nasal sounds, but will also be The study confirmed that the nasometer is not only sensitive and reliable in the diagnosis of hypernasality, but also will be important in the recovery of postoperative palatopharyngeal closure.
3.2 Management of compensatory articulation disorder
Patients with cleft palate have a series of compensatory articulatory habits that have become fixed neuromuscular motor patterns integrated into the patient’s speech system during speech development due to congenital incomplete palatopharyngeal closure, which determines that it is difficult to completely correct the speech disorder caused by cleft palate with surgical treatment alone.
The tongue is an important component of the organ of articulation. Some patients with good postoperative palatopharyngeal closure have speech disorders due to abnormal tongue position during articulation, including palatalized articulation, lateralized articulation and nasal articulation. Palatalized constrictions are one of the most frequent abnormal speech sounds in postoperative cleft palate patients, which are produced by abnormal movement of the organ of constriction. Through tongue flattening exercises to flatten the tongue body and restrict tongue retraction, and then correctly induce the tongue-palate contact position according to the constriction position of each consonant, supplemented by the correct air outlet, repeated practice, experiments have confirmed that this method can significantly improve patients’ speech intelligibility. With the development of electronic biofeedback technology, some foreign people have applied Elecbopalatography (EPG) to speech therapy. During articulation, the tongue-palate contact situation can be displayed on the screen, together with the standard graphics of the tongue-palate contact of each consonant.
Pharyngeal and vocal fold compensatory speech mainly includes vocal fold blast, pharyngeal fricative, pharyngeal blast and epiglottis fricative, among which vocal fold blast has the highest incidence. It is controlled by the sudden closing and opening of the vocal cords and the release of airflow in the process of articulation. This kind of patients often cannot hear the consonant component of syllables when pronouncing and seriously affect their speech communication. Scholars believe that the later the surgery is performed, the easier it is to form this pronunciation habit, and this kind of compensatory dysphonia mainly occurs in the consonants that require high oral pressure. The following points should be paid attention to when correcting vocal fold blasts: ① Firstly, let the patient practice voice recording to let them understand where their pronunciation errors are; ② While practicing tongue and palate functions, try to keep the laryngeal muscles and vocal folds in a relaxed state; ③ When choosing target sounds, focus on consonants and syllables that are easy to pronounce correctly such as bilabial air-feeding cork p and pu; ④ Emphasize the importance of consolidation training.
For compensatory dysphonia, most scholars agree that it is a simple phonological problem caused by structural abnormalities, but some foreign scholars think that the impact of compensatory dysphonia on language development should be paid attention to. Therefore, in addition to phonological training, we should also promote the development of cognitive, expressive and reasoning abilities of the child in order to achieve normal language level. During the growth of the child, parental communication and education also play an important role in inducing the correct pronunciation of the child.
3.3 Application of speech-assisted devices in speech therapy
For patients with structural phonological abnormalities that are not suitable for surgical treatment, the use of phonological aids together with speech training can correct compensatory dysphonia at an early stage and ensure the normal development of speech.
For marginal palatopharyngeal insufficiency, it has been suggested that gradual reduction of the size of the pharyngeal bulb can promote the recovery of palatopharyngeal closure function, promote the contraction of the palatopharyngeal muscles, and compensate for the palatopharyngeal closure. The success rate of the second-stage surgery for voice improvement can be increased.
The palatal lift speech aid uses a palatal bar to elevate the soft palate to an appropriately constricted position, narrowing the palatopharyngeal cavity and effectively improving nasal sounds and nasal leakage. Studies have shown that the palatal bar can elevate the soft palate to a certain height, and the palatopharyngeal closure can be accomplished with mild movements of the soft palate, making the soft palate with reduced motor function also have the potential for palatopharyngeal closure . In China, a number of units have also started to use voice assist devices to correct incomplete palatopharyngeal closure after cleft palate surgery. However, regardless of the speech-assisted device used, speech training must be performed to improve the child’s articulation.
3.4 Treatment steps.
Establish a good doctor-patient relationship.
Analyze and assess the patient’s articulatory movements and design a correction plan.
From easy to difficult, help the patient to observe and analyze his or her phonological errors.
Discuss with the patient in a planned and phased manner the correct way of articulation, and gradually link the articulatory training with the correct speech, so as to shape the correct articulation.
At the end of each session, treatment priorities should be listed and then home exercises should be assigned.
Depending on the condition, different behavioral remediation techniques are applied and appropriate feedback and reinforcement are given for each good performance.
As much as possible, the correctional training goals should be quantified so that parents and patients can master them.
Usually 10-20 sessions are given, about once a week.
3.5 Behavioral treatment methods.
Demonstration method. The modeling approach is a method of establishing, reinforcing, or diminishing certain behaviors and is particularly effective for preschool patients aged 4 to 5 years. Within the framework of the demonstration method, a combination of cognitive-behavioral treatment techniques such as reinforcement and attenuation are used. In cognitive-behavioral game therapy, the therapist adds the role of demonstration to the game to, first, increase the patient’s interest in model learning and, second, reduce his or her resistance to treatment. The therapist can use toys, pictures, and other props or personally demonstrate the behavior that the patient needs to learn, and when the patient shows a positive connection to the paradigm, provide timely reinforcement so that the behavior expected in therapy can be gradually established. For patients 6 years of age and older, the therapist can demonstrate verbally and present solutions to specific problems. Also talking is a demonstration in itself.
Role-playing method. Role-playing can fully engage the patient in therapy. For example, playing the role of a spitting person (tongue root training); an elephant with a long trunk (tongue extension training), etc. For patients under 6 years of age, the therapist can implement the role play by modeling while the patient learns to establish or eliminate behaviors through observation.
Association of behaviors. Patients will develop a large number of newly constructed behaviors in therapy, both correct and incorrect, most of which are incorrect. The therapist has to discover the correct prosodic actions through careful observation and provide timely reinforcement and rewards to solidify the correct actions. Appropriate praise is given when the child actively attempts to learn a new articulation. Once the correct motion is solidified, the correct motion can be associated with the correct phonology. This association can be achieved by direct instruction and encouragement from the therapist or can be used by the parents in situations outside of therapy. The behavioral association establishes a mapping between listening, thinking, and speaking, creating a stable cognitive-behavioral pattern.
3.5 Assessment of treatment effects
The average treatment duration was 8 weeks for 4-5 years old; 10 weeks for 6-12 years old; 14 weeks for 13-18 years old; and 20 weeks for 20 years old and above. Speech intelligibility of patients who completed treatment: cleft palate word list test > 99%, continuous speech test > 95%.
4.Summary
Cognitive-behavioral play therapy combines play and simple cognition with language intervention, which greatly reduces the difficulty of treatment for younger patients. For older patients and even adults, cognitive-behavioral therapy is more effective. During the treatment process, patients are not only learning to change their behavior, but gradually become active participants in the treatment. Post-operative speech disorders after cleft palate are not only a category of maladaptive behavior, but also a cognitive impairment in speech. Applying the principles and methods of cognitive-behavioral play therapy can better correct this speech disorder.
Speech therapy, as part of the cleft palate sequence, will play an important role in the comprehensive treatment of cleft palate. Establishing a scientific and effective postoperative speech therapy program requires an in-depth study of speech pathology and a rational treatment plan for various mechanisms of pathological speech occurrence. With the rapid changes in science and technology and the continuous enrichment of methods and means of voice therapy, voice therapy will change from simple voice training to comprehensive treatment by various means. The recovery of the patient’s voice function will become an important indicator of the success of cleft palate treatment.