We recently asked Ann W. Kummer, author of Cleft Palate and Craniofacial Conditions: A Comprehensive Guide to Clinical Management, Fourth Edition, for her expertise in diagnosing a nasal emission.
Read what Dr. Kummer had to say:
Question: I see a patient with a history of cleft lip and palate. He has a fistula about the size of my finger tip and located just behind his maxillary teeth. He has inconsistent nasal emission on certain sounds. How can I tell if it is due to VPI or caused by the fistula?
Answer: Differential diagnosis of the cause of nasal emission (and/or hypernasality) can be particularly challenging if the child has an oronasal fistula. If the fistula is small, it is unlikely to cause nasal emission during speech because the airflow in the oral cavity primarily flows horizontally across the opening. If the fistula is 5 mm or more in diameter, nasal emission may be noted with the production of sibilant sounds because as the tongue elevates to produce these sounds, it pushes some of the airstream into the fistula. If the fistula is very large, there may be some hypernasality as well as nasal emission, although hypernasality is more likely to occur due to velopharyngeal insufficiency than a fistula.
There are two ways to determine whether nasal emission is from a fistula, from VPI or from both. One way is to occlude the fistula with chewing gum, Fruit Roll-ups (which are dry and sticky), or edible paper. Then you compare the amount of nasal emission with occlusion and without occlusion of the fistula. This is time consuming and messy, however. A better way is to compare the amount of nasal emission on /k/ with the amount of nasal emission on /t/ and /s/. This is because the airstream from production of a /k/ sound flows horizontally over the opening and not up into the fistula. In contrast, the tongue tip movement on /t/ and /s/ can direct the airstream into the fistula. To do this, it is best to amplify the sound of the nasal emission by using a bending straw. Put the short end of the straw at the entrance of the child’s nostril. Put the long end near your ear. Then listen to the amount and loudness of the nasal emission on the /k/ sound versus the /t/ and /s/. The differential diagnosis can then be made as follows:
- If there is no nasal emission on /k/ but nasal emission on anterior sounds, then the source of the nasal emission is the fistula.
- If there is nasal emission on the /k/, then there is VPI.
- If there is more nasal emission on anterior sounds than /k/, then it is caused by both VPI and the fistula.
- If there is significant hypernasality on vowels and nasalization of /g/, then there is VPI.
About the text:
Cleft Palate and Craniofacial Conditions: A Comprehensive Guide to Clinical Management, Fourth Edition is ideal for the graduate course on cleft palate and craniofacial conditions, or as a source book for healthcare professionals who provide services in this area. Updated with full color illustrations and photos, the Fourth Edition of this bestselling title has been reorganized to improve clarity and flow, with new references and information reflecting the most current research in the field. Key features such as Case Studies help the learner understand how to apply key information in a clinical setting, while Speech Notes highlight how anomalies and surgeries affect speech and resonance.
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