Clinician’s Corner: Structure or Function?

ACPAACPA News, Clinician's Corner

Ann W. Kummer, Phd

That is the question… when it comes to considering speech therapy.

I once made a comment in a lecture at an international meeting that speech therapy cannot correct VPI. After the lecture, I was approached by a plastic surgeon who said that I must not be very good at my job. He told me that the speech-language pathologists with whom he works (my mother would be proud of my grammar here) correct VPI all the time! Unfortunately, this is a common misconception. Therefore, I would like to take this opportunity to clarify.

Velopharyngeal insufficiency (VPI) refers to a structural defect, most commonly due to a history of cleft palate, submucous cleft, or adenoidectomy. A structural abnormality can only be corrected by changing the structure through physical management, such as surgery. I used to think that when a child had a small velopharyngeal gap, that I could correct it in speech therapy, and I was partially right. I corrected it in speech therapy while the child was concentrating and speaking slowing. However, as soon as the child walked out the door, he still had the nasal emission. I have come to realize that even small velopharyngeal openings require surgical intervention if the family wants correction.

Although speech therapy cannot correct VPI, it can correct the abnormal function that results from VPI. When kids have VPI, they typically compensate by producing oral sounds in the pharynx, where they have adequate airflow to produce sounds. These abnormal productions include glottal stops, pharyngeal plosives and pharyngeal fricatives. When secondary surgery is done and results in a correction of the VPI, the hypernasality (abnormal resonance) will be eliminated because resonance is solely due to the function of the velopharyngeal valve. However, the nasal emission will persist. This is because when sounds are produced in the pharynx, the airflow continues in a superior direction and is emitted through the nose. Speech therapy is needed in this case to correct placement, which will then correct the nasal emission.

To summarize, speech therapy cannot correct VPI, which is due to abnormal structure. (Speech-language pathologists cannot fill in a defect or even stretch the velum.) Speech therapy CAN correct abnormal function that causes persistent nasal emission after surgical correction of the velopharyngeal valve. Therefore, before considering speech therapy, we need to ask: Is the abnormal speech due to abnormal structure or abnormal function? That is the question!

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