Transcript 学生习作二：腭裂的嗓音治疗

Voice Therapy of
Cleft Palate
10言听
蔡静雯
李伟
杨丽洁
Topics
What is Cleft Palate?
 definition
 development
Incidence
Etiology
Classification
Symptoms
Repair
Acoustic Characteristics
Speech Therapy
part 1 What is Cleft Palate?
* definition
* development
What is Cleft Palate?
 a kind of facial cleft*
 * facial cleft: Tissier1973 numbers the clefts from 0 to 14.
4 of the most common ones:
lateral cleft（面侧裂）, oblique cleft（面斜裂）,
cleft lip(palate)（唇/腭裂）, median cleft（面正中裂）
What is Cleft Palate?
 congenital malformation of
embryonic origin （先天性胚胎畸形
）
 occurs by itself or together with an
alveolar or lip cleft（齿槽或唇裂）
What is Cleft Palate?
 how is the cleft palate comes to be ?
 incomplete development in the early weeks of
pregnancy
 the face is being formed - the top and the two
sides develop at the same time and grow
towards each other, finally fusing（融合） in the
middle.
 The lip and primary palate develop at 4 to 6
weeks of gestation, while the secondary palate
develops at approximately 9 weeks.
part 2 Incidence
* racial difference
* sex difference
* differences in types
Incidence
1/750
(safe & conservative estimated)
 Cleft Palate alone: 1/2,500 according to reports
from ADA.
 racial difference: [by Vanderas(1987)]
North American Indians
3.74/1000
Japanese
0.82-3.36/1000
Chinese
1.45-4.04/1000
the Whites
1.99-2.69/1000
the Blacks
0.18-1.67
 [these differences could be attributed to environmental
and genetic factors ]
Incidence
 sex difference
* CLP: twice as often in males than females / more
severe deformities
* CP: females are more than or equal to males
 differences in type
* varies, but hovers around a 3:3:4 ratio
part 3 Etiology
* some related causes
Etiology
 parental age （孕龄）
 drug use （药物）
 infections during pregnancy （孕期感染）
 smoking or/and drinking during pregnancy
 heredity , Family History （遗传）
 X-ray,microwave （辐射）
 deficiency of vitamin C,D,B （维生素C\D\B缺乏）
 environmental Factors （环境）
 Animal models have demonstrated that vitamin A,
corticosteroids, and phenytoin produce cleft
palate when given in pregnancy. （维A多度使用）
part 4 Classification
* soft palate alone
* incomplete
* complete
Classification
 1- Cleft of the soft palate
only（软腭裂）
 2- Incomplete cleft of
palate(unilateral/bilateral):
not extend into the nose
 3,4- Complete cleft of
palate(unilateral/bilateral):
extend into and involves
the nose
1
3
2
4
Classification
1- Cleft of the soft palate only
Classification
2-unilateral Incomplete cleft of palate
Classification
cleft palate together with
an alveolar or lip cleft
cleft palate only
3-unilateral complete cleft of palate
Classification
cleft palate together with
an alveolar or lip cleft
cleft palate only
4-bilateral complete cleft of palate
part 5 Symptom
* 5 of the symptoms
Symptom
 Separation of the palate
* Velopharyngeal closure
 Speech
and/or language problem: Nasal voice*
During speech and swallowing the palate moves both
superiorly and posteriorly against the posterior
pharyngeal wall to separate the oral pharynx and nasal
pharynx.
Recurrent ear infections
When palate is cleft ,however, not only is there
Velopharyngeal closure but, in addition ,
inadequate
Nasal regurgitations
during bottle feeding（喂奶
the opening in the palate permits the air stream to
时鼻腔返流）
pass
partly through the nose. Thus ,the air stream
,passing through both nasal and oral cavities, can not
be altered properly to produce the normal sounds.
 Psychological problems: of the adolescent or
adult patients and their families.
Symptom
 Nasal regurgitations during bottle feeding（喂奶
时鼻腔返流）
 A cleft feeding nipple must have:
 1 a large enough opening to allow the formula to flow
easily to prevent sucking fatigue, but it must not be so large
as to cause choking.
 2 Nipples should be soft and compressible（可压缩）,
allowing liquid to flow easily.
 3 the hole in the nipple designed for a premature neonate
may need to be enlarged to increase the flow of milk (
performed by creating an X-shaped opening)
Symptom
 Nasal regurgitations during bottle feeding（喂奶
时鼻腔返流）
squeeze the bottle in conjunction with the
baby's sucking/breathing rhythm to assist with
swallowing
part 6 Repair
* the goal
* the age
* the procedures
Repair
The goal:
to create a velopharyngeal valving mechanism
that is capable of seperating the oral from the
nasal cavities during speech.
[primary goal]
 added benefits: easier intake of food,
reduction in the number of upperrespiratory
infections, and improvment to the status of the
middle ear.
 for parents: experience a psychological lift
when the cleft is repaired
Repair
 The age: The optimal timing for cleft palate repair is
controversial.
early
* In China: most commonly
at 1.5 to 2 late
years old.
【体重在12公斤以上，WBC（白细胞）在10,000以下，血红
better speech
better of
facial
growth
With
this
approach, the part
the
蛋白在10克以上，无发热﹑咳嗽﹑流鼻涕现象。】
advantages
development and less
palate hearing
necessary
loss for normal speech
is intact,
but proposed.
without the
a development
two-stage
repair
has-been
Involves:
impair facial
growth
growthnasal
restriction
growth andof closing the hard
* closure of the soft palate between
6 to and
12 m
hearing
palate.palatal growth can be Poor speech
disadvatages
outcomes
restricted
with
early
[ creates a functional palate, reduces the chances
repair
that fluid will
develop in the middle ears, and aids in
the proper development of the teeth and facial bones
]
* closure of the hard palate between 15 to 18 m
Repair
How:
 before the surgery:
# a speech therapist or feeding therapist -- feed the
child to gain weight and be healthy
# test blood / take medical history / physical
examinations
# 10 days before: stop taking some drugs like
Aspirin
# on the day: arrive on time / give a small sip of
water / make sure the child's health
Repair
How:
 during the surgery: 2 or 3 hours:
# have general anesthesia (asleep and not feeling
pain)（全身麻醉）
# two main types of the surgery:
* palatoplasty（腭成形术）
* pharyngoplasty（咽成形术）
Both palatoplasty and pharyngoplasty be performed to
recover the anatomy and physiological function of
the palate.
Repair
How:
 during the surgery:
* palatoplasty（腭成形术）：利用
裂隙邻近的组织瓣封闭裂隙、延长软腭，将移位
组织结构复位，以恢复软腭的生理功能。【单瓣
手术、多瓣手术(以两瓣常用)、梨骨瓣手术、岛
状瓣手术、逆向双“Z”形瓣手术、提肌重建术】
Repair
* palatoplasty（腭成形术）
局部浸润
拨断翼钩
松弛切口线
剪断腭腱膜
剖开裂隙边缘
分离鼻腔黏膜
分离粘骨
膜瓣
分层缝合
游离血管
神经束
松弛切口填塞
Repair
* palatoplasty（腭成形术）
Repair
How:
 during the surgery:
* pharyngoplasty（咽成形术）
：利用咽后壁组织瓣，增加软腭长度和咽侧组
织瓣缩小咽腔宽度，以改善腭咽闭合。【咽后壁
组织瓣手术和腭咽肌瓣手术】
Repair
* pharyngoplasty（咽成形术）：
切口设计
关闭咽喉
壁创面
局部浸润麻醉
分离咽后
壁组织瓣
示缝合后口
腔面
示缝合后矢状
面
Repair
* pharyngoplasty（咽成形术）：
Repair
How:
 after the surgery:
# be in the hospital for 5 to 7 days / Complete
recovery can take up to 4 weeks.
# surgery wound be kept clean / not be stretched
/ not have any pressure 3 to 4w
# when heals, on a liquid diet
# wear arm cuffs to limit arm movement / no
putting in mouth
part 7 Acoustic Characteristics
* VPD
* compensatory speeche errors
Acoustic Characteristics
Children with a histroy of cleft palate are at risk
of for resonance and speech problems due to
velopharyngeal dysfunction (VPD，腭咽闭合
功能不全), there are 3 main types of VPD:
 Velopharyngeal Incompetence
 Velopharyngeal Insufficiency (VPI)
 Velopharyngeal Mislearning: This type of VPD will
most likely respond to speech therapy
Acoustic Characteristics
 VPD due to incomplete closure of the velopharyngeal
valve may include:
 Hypernasality（鼻音功能亢进）
 Nasal Air Emission（鼻漏气）
 Nasal Rustle/Turbulence（鼻湍流）
 Weak or omitted consonants.
 Short utterance length（句长缩短） due to loss of
air through the nose.
 Compensatory speech errors（代偿性发音）
 Phoneme-Specific Nasal Emission of Air
Acoustic Characteristics
 VPD due to a blockage or obstruction（阻塞） may
include:
 Hyponasality（鼻音功能低下）
 Cul-de-Sac Resonance（共鸣困难）
Acoustic Characteristics
 Compensatory speech errors（代偿性发音）: These
errors are often attempts to adjust for nasal air loss.
 speech sound distortions（语音失真）
 glottal stops （声门塞音）
 nasal substitutions（鼻音替代）
 pharyngeal fricatives and stops（咽擦音、咽塞音
）
part 8 Speech Therapy
* Relaxations
* Methords related to
certain problems
Speech Therapy
放松训练
针对性训练
Speech therapy
Relaxations（放松训练）:
 按摩手术瘢痕及冰冻刺激促进瘢痕软化
* 增加软腭的长度
* 改善腭咽部肌肉软组织感觉和运动功能
 练习发“啊”音，打哈欠，发音时双肩伸直用力推前
面的桌子
* 抬高软腭，使悬雍垂与咽后壁接触
 指导患儿练习口唇和舌的肌肉活动【口部运动操】
Speech therapy
Methords related to certain problems（针对
性训练）:
1 腭咽闭合功能训练Velopharyngeal function training
 气流传导异常的矫治：
* proper air flow location（气流部位的识别、正确气流部位
的建立）
* 采用听觉视觉触觉等
 口鼻呼吸分离训练法：帮助建立正确的口鼻腔气流意识
* CPAP(continuous positive airway pressure)
* 锻炼腭咽部结构，提高软腭上抬的意识和力量
 口腔共鸣法：发音时口腔充分打开，体会气流从口腔流出的感
觉
Speech therapy
Methords related to certain problems（针对
性训练）:
2 增强节制呼吸功能训练，提高言语呼吸功能Improving
respiratory function
 提高肺活量，增加句长：
* 用力呼气训练、缓慢呼气训练
* MPT、MCA
* 停顿换气训练
 提高呼吸支持能力，控制能力和言语呼吸功能
* Combine with DR.Speech S1.S2.S5
Speech therapy
3 强化正确的构音器官运动训练，纠正因不良代偿发音习
惯而引起的功能性语言障碍Correct Compensatory
speech errors
 根据错音的类型进行口面构音器官的运动训练
* 采取练舌法和练唇法。
 舌后缩习惯的矫正
* 压舌板 or 汤匙柄 or 咬舌发音
* 伸舌法 / 前位音法
 纠正错误的发音
* the same as articulation therapies
* 发音部位、发音方式异常的矫治
Speech therapy
Methords related to certain problems
（针对性训练）:
4 Phychotherapy （心理治疗）run throught
from the beginning to the end.
 for both the children and the family