“I’m looking for clouds coming from your nose,” speech-language pathologist Katie Engstler, MA, CCC-SLP, tells a child as she holds a small mirror under his nostrils while he speaks. Fogging of the mirror indicates that air is escaping through the nose, which can result in a nasal-sounding voice or noises like snorts.

Children with cleft lip and palate and other craniofacial conditions generally have normal language development — learning of words and sentence structure — but may have problems producing the different sounds necessary for speech. Speech-language pathologists, who have completed a two-year master’s degree program as well as a fellowship, are important members of the craniofacial team at Children’s Hospital Boston. Both Katie and her colleague AsakoWehner, PhD, CCC-SLP, evaluate the speech and language of children in the Cleft and Craniofacial Clinic, usually starting at the age of 12 to 18 months. After children turn 3, the focus is on speech production skills alone. If problems are detected, the speech-language pathologists recommend services for the child. Often services are provided within the community through early intervention or school programs.

Speech problems generally fall into two categories: articulation and resonance.“Articulation or speech production difficulties are often related to structural differences in the mouth due to craniofacial anomalies or to bad habits formed before the palate is repaired,” says Katie.“They may also be developmental in nature.These difficulties can take the form of sound substitutions, omissions or distortions.

“Articulation problems require speech therapy to teach the child correct placement and marking of consonants.This therapy should be fun and motivating for the child, involving lots of play, games, and multisensory cues.”

Excessive nasal resonance or hypernasality is a problem specific to children with cleft palate.To understand this, let’s first look at what happens during normal speech: Air from the lungs and sound vibrations from the vocal cords travel up through the throat (pharynx) and then enter the mouth.The palate and the walls of the throat block the air and sound from going into the nose. But if the palate and throat don’t close effectively — condition known as velopharyngeal insufficiency or VPI — air goes up into the nose and makes the child sound hypernasal. This can occur, explains Katie, if the palate is too short or if the muscles aren’t working correctly.

Diagnosing VPI

Using a mirror to look for “clouds” is one easy way to see if air is coming out of the nose.Another involves plugging and unplugging the nose while the child talks.

“We have them say different words and listen to the pressure behind their sounds,” says Katie.“If the sounds are a lot stronger with their nose blocked, they might be losing some of the pressure out of their nose.

“You hear hypernasality with the sound of vowels,” she adds.“So if the sound becomes clearer with the nose blocked, that indicates some hypernasality.”

If VPI is a suspected, the speech-language pathologists may refer the child for an x-ray study, known as speech videofluoroscopy. This involves taking a moving x-ray picture while the child is talking to determine why air is escaping.

Another diagnostic test that may be used is nasal endoscopy. In this procedure, an otolaryngologist or ears, nose, throat doctor inserts a slender telescope with a tiny camera attached inside the nose.This allows the doctor to see inside the nasal passages.

Treatment for VPI

Cleft repair generally resolves the issue of VPI, but sometimes the problem persists.“About 10 to 15 percent of kids have VPI after a cleft repair,” says Katie. “Those children often require a secondary operation. Hypernasality and nasal air emission are structural issues that can’t be corrected by speech therapy.That’s when we look at how their palates are functioning to see if they would benefit from a surgical procedure to get better closure.”

Postoperative speech therapy may be needed to help the child relearn how to produce sounds using the corrected structure.