Cleft Lip and Palate, and Voice - Essay Example

CLEFT LIP AND PALATE, AND VOICE Introduction Cleave lip is the result of the failure of Orbicularis oris to fuse and form the circular muscles that compose a full human lips (Marieb 2003). As superficial face muscles of the skull, it originates from the mandibles and maxillae and finds insertion into the adjacent skin and different muscles around the mouth (Marieb 2003). These skeletal, spherical muscles of the anterior part of the oral cavity are responsible for its opening as well as the protrusion of the lips (Marieb 2003). Orbicularis oris gained its name for this particular location, shape and task. Primarily, the congenital defect called cleft lip takes place during the developmental stage of the human embryo which begins at about thirty five (35) days from the first day of fertilization (Seeley, Stephens, and Tate 2005; Iozzio 2005). The human embryonic face initially gains form from the union of ectodermic cells which forms ectodermic tissues. Five (5) bunches of these tissues are normally formed. Out of these, a first bunch of ectodermic tissues shapes the forehead where two groups of protrusions on each side shape the nose, while the tissues in between makes up the center of the upper lip and the jaw (Seeley, Stephens, and Tate 2005). The next two bunches of ectodermic tissues shapes the upper lip and the upper jaw or the maxillae, while the last two bunches shapes the lower lip and the lower jaw or the mandible (Seeley, Stephens, and Tate 2005). Normally, the facial tissues initially grow and develop with the multiplication of cells as well as development and growth of connective tissues cells increasing the size of the nose and subsequently uniting at the junction where the tissues meet called the midline or the nasal septum shaping the upper jaw and lip (Seeley, Stephens, and Tate 2005). In congenital abnormality, the connective tissues fail to join the nose tissues resulting to cleft lip. However, if normal growth and development of the upper jaw and lip will ensue, the palate will begin to be shaped forming the roof of the oral cavity uniting again at the midline within about fifty six (56) days of embryonic development (Seeley, Stephens, and Tate 2005). Nevertheless, in cases where genetic dictates does not produce connective tissues for the purpose of joining the developing mouth roof, then, cleft palate would result. On the other hand, the other parts of the mesoderm and ectoderm layers of the developing embryo also develop into the other upper respiratory system parts such as the nasopharynx, oropharynx, and the laryngopharynx, and the lower respiratory tract parts such as the larynx, trachea, bronchi, and the lungs (Seeley, Stephens, and Tate 2005). Conventionally, the larynx consists of epiglottis, vestibular fold or the false vocal folds, vocal folds or the true vocal cords, thyroid cartilage, and cricoid cartilage. The maturation of the embryo would usually and spontaneously expose the major facial aspect which would also be the matured nose naturally made up of a combination of bone, and cartilage held in place by multitude of connective tissues underneath layers of epidermal cells making up the skin (Seeley, Stephens, and Tate 2005). Normally, the nasal cavity starts from the pair of nose that opens up with a pair of external nares, a space called vestibule lined with cilia and mucus glands, partitions called inferior conchae, middle conchae, and superior conchae up to the choanae which is a space right before the opening of the auditory tube, right above the soft palate that ends with uvula, and is continuous with the nasopharynx (Seeley, Stephens, and Tate 2005). This nasal cavity together with its structural parts and functions is separated from the oral cavity anteriorly with a hard palate. Anteriorly, the oral cavity starts with the upper lip and the upper jaw, and the first part of the digestive tract (Seeley, Stephens, and Tate 2005). Naturally, this is continuous with the pharynx, the common passage of air, food and water, and the larynx that is correspondingly connected to the upper part of the trachea. The trachea connects itself to the bronchi of the lungs. Ventilation of the lungs or breathing necessarily passes air into and out of the lungs. The air that gets into the lungs is from the atmosphere that enters through the pair of nares and travels via the nasal cavity, pharyngeal cavities, laryngeal cavity, trachea, and the bronchi. While the air that is expelled from the lungs through exhalation passes out through the same routes, but may cause vibration on the vocal folds primarily producing sound or the more controlled vestibular folds voice (Seeley, Stephens, and Tate 2005). 1. Velopharyngeal Facial Syndrome . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5 2. Articulation Difficulty in Vocalization . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6 2.1. Complex Temporal Relationships . . . . . . . . . . . . . . . . . . . . . . . . . . 6 3. The Serial Order Problem . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7 4. The Degrees of Freedom Problem . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8 5. The Context of Sound Creation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8 5.1. Co-articulation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8 6. Process of Spoken Language . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9 7. Voice Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10 8. Speech Production. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11 9. Implications of CLP . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11 Outline: The succeeding paragraphs discuss and illustrate the relationship of the now familiar Velopharyngeal congenital defect to voice and speech production. It attempts to bring into fore the superlative promise of modern technology as revealed by results and findings of some researchers to assist in the reparation and management of the acknowledged physical limitation. As well, the implications of such disorder to the growth and development of the affected children are briefly presented. 1. Velopharyngeal Facial Syndrome Velopharyngeal Facial Syndrome more commonly known as cleft lip and palate are acknowledged by Medical professional to cause minor learning and speech problems (Persson et al. 2006, Park et al. 2000; Sell et al. 2005,). These days, the defect can be readily repaired by surgery, but the resulting voice quality may vary depending on the extent of the fused structures (Van Lierde et al. 2003). Some patients were observed to have more of a nasal voice even after surgery, but, generally the result is close to normal (Van Lierde et al. 2003). Children with this type of disorder are also at an odd in terms of speech and literacy, especially those who have extensive cleft in the palate which results to loss of hearing and subsequent delays in speech development (Lewis et al 1993). Experts and researchers cited communication problems such as wrong pronunciation, incomprehensible speech, weak consonants especially the letter /s/, substitutions of letters, omissions, loss of intra-oral pressure, pharyngeal fricative and glottal stops, hyper-nasal resonance, and hypo- nasality (McWilliams et al. 1969). On the other hand, some or few subjects may exhibit any of the following: hoarse voice, soft voice, reduced loudness of voice, monotone voice, and strangled voice depending upon the degree of the cleft (Van Lierde et al. 2003). Countless advertisements, professionals, experts whether in the local or on the global level have indicated the interest in assisting cleft lip and palate subjects, especially those who have undergone surgery, in their bid to communicate using speech. The diagram below shows the development of spoken language, verbal communication formulation, and vocalizations production. 2. Articulation Difficulty in Vocalization Cleft lip children are commonly known to have articulation difficulty in vocalizations. This difficulty arises from the point the growing child begins to attempt talking. Obviously because though there may be voice coming from the vibrations of the vestibular folds produced by the passage of air, the tongue controls this voice and manipulates the air to form audible words (Marieb 2004). As it does, it needs solid surface on the upper lip to control air release. 2.1. Complex Temporal Relationships “Diagram showing complex temporal relationships among the movement in a phonetic sequence; a is the point where the jaw and tongue have the greatest influence on shaping the vocal tract. (From Kent, R.D. [1989], Sensorimotor aspects of speech development. In Aslin, R.N., Alberts, J.R., & Petersen, M.R. [Eds.], Development of Perception: Psychobiological Perspectives [Vol.1, pp. 162-185]. New York: Academic Press.)”(Kent, Adams, and Turner 1996, 10). Title: Principles of Experimental Phonetics; Publisher: Mosby; Publication Date: 1996; Page No: 10 The figures above reveal that a series of control elements is not sufficient to generate pronunciations in verbal communication (Kent, Adams, and Turner 1996). This is because of the serial order problem, the degrees of freedom problem, and the context-sensitivity problem of the motor control. 3. Serial Order Dilemma In the serial order dilemma the temporal sequencing of speech events likewise poised a dilemma to forward looking specialist who continually disputed the specific basis for succession of letters in a word to create a particular message or language (Kent, Adams, and Turner 1996). For example, what mechanism controls the placements of either vowel or consonant in a word like “Voice”: where a consonant comes before two vowels, followed by a consonant and another vowel? Experts on the field deduce feedback mechanism hovering within the length of events in a word. 4. Degrees of Freedom Problem The degrees of freedom problem on the other hand takes into account the vastness of the speech production system as was mentioned by Gracco in 1990 to be consisting of seventy (70) varied muscular movements (Kent, Adams, and Turner 1996). This meant the collaboration of the physiology of the various anatomical structures found within the oral and respiratory cavities. For example, the muscular tongue which is attached to the lower jaw has intrinsic muscles that allows it to change shape, and extrinsic muscles (Seeley, Stephens, & Tate 2005) that allows it to move in addition to the lower and upper lips, lower and upper jaws, nasal cavities and its respective organs, respiratory cavities and its respective organs as well as its individual physiological functions to utter the phrase “The flowers are in bloom”. 5. Context of Sound Creation Finally, the context in which a sound is created may vary with motive or intentions and not just the mere message of the words. Thus, in the face of a huge extent with which the tongue and its ancillaries may move, professionals believed in co-articulation. 5.1. Co-articulation “Examples of co-articulation: A, Variation in place of constriction for a velar consonant. B, Variation in lip configuration for the fricative /s/. C, Variation in velar position for a vowel. (From Nielson, M.D., & Neilson, P.D. [1987]. Speech motor control and stuttering: A computational model of adaptive sensory-motor processing. Speech Communication, 6, 325-333.)”(Kent, Adams, and Turner 1996, 9). Title: Principles of Experimental Phonetics; Publisher: Mosby; Publication Date: 1996; Page No: 9 Kent and Minifie (1977) mentioned speech system adjustments for a word segment (Kent, Adams, and Turner 1996). Such that, for instance sounding out the vowel “O” varies with the tongue and the pharyngeal elevator muscles opening the auditory tube after the choanae in the nasopharyngeal cavity, equalizing the pressure between the middle ear and the atmosphere (Seeley, Stephens, & Tate 2005). In addition, lips participation on the articulation of the letter is obviously critical to the audible sound of the vowel (Kent, Adams, and Turner 1996). 6. Process of Spoken Language “A general diagram of the processes of spoken language, including language formulation, and speech production” (Kent, Adams, and Turner 1996, 6). Title: Principles of Experimental Phonetics; Publisher: Mosby; Publication Date: 1996; Page No: 6 The development of spoken language primarily begins with cognition, which refers to a well-thought of design or mode of satisfying the realized need for communications prior to verbalizations which normally comes together with some sort of passion for the intellectual activity of using languages (Kent, Adams, and Turner 1996; Emmory 2002). Conventionally, this enthusiasm would come to every growing child who is apt to follow syntax, where words are arranged chronologically into sentences to form the message. Semantics may sometimes be routine as it may come out naturally from the passion of talking, while phonology or the standardized sounds or words in the language may be a barrier at the outset of the learning process of a cleft lip and palate despite surgery and healing. After some time in the activities of learning, there is the greater probability of the Child’s development of a glossary of terminologies as well as close to correct pronunciations of appropriate words for a spoken language (Hirano 1981). 7. Voice Management Voice management among cleft lip and palate will have to be more extensive considering the stages as illustrated, plus the fact that as Meyer and Gordon (1985) cited there are three (3) levels of speech organizations: multi-unit representation, articulation representation, and motor control (Kent, Adams, and Turner 1996). In all probability, this third level of speech organization posit the most challenge gauging from the concerns of direct muscular regulation as well as proper muscular collaboration in the physiology of speech production. 8. Speech Production Speech production or vocalization which is not so easy with the normal people is most likely difficult with those born with the congenital defect of cleft lip and palate despite surgery as verbal communication is standardize by a series of linguistic elements like phonemes (Kent, Adams, and Turner 1996). Phonemes or distinguishing an utterance from another (The Merriam-Webster Dictionary 2004) is a real initial barrier. Nevertheless, vocal tract control may adjust after sometime with the assistance of some speech pathologist where children of the kind are supported with speech therapy after surgery despite cost and length of time (Riski 1995). Recently however, with the rise in cost of speech therapy, parents of children with the disorder have sought governmental assistance to sustain the growing need. 9. Implications of CLP From these perspectives, the impact of the issue will not only be on the scar but also with the kind of voice that a child may develop after surgical attempts to fuse cleave palate and lip as well as dental and auditory problems (Baken 2000). Practically, either a throaty or a soft voice (Grunwell et al. 2001) which may only be audible at about two (2) to three (3) years of age would most likely be one source for delays in the development of vocal or oral communication proficiency (Green 1960; Eliason and Richman. 1990). Usually, voice volume is largely reduced after surgery and becomes quieter lending to the problem of decreased air pressure resulting to hyper-nasal utterances. For example, the lack in air pressure would cause the mispronunciation of vowels and two vowel sounds joined in one syllable to form one speech sound as in a dipthong (Merriam-Webster Dictionary 2004). All this difficulty may be surmised to fall within the context of motor development at the babble stage of the child (Oller 2000; Tingle 1990). Patterns of growth and development of speech is usually associated with babble stage, the developmental stage where repetitive movements of the jaws, lips, tongue, and vocal cord vibrations takes place (Oller 2000; Werner and Kaplan. 1984). This rhythmic repetitive babble as well as hand banging are observed even with victims of Down syndrome as mentioned by Cobo-Lewis et al (1996) (Oller 2000), so, it is plausible that the same motor developments occur with cleft lip and palate children, despite some delays. Although, babbling is the simplest form of a growing child’s speech, its repetitive nature develops primarily recurring jaw movements which would eventually mature into phonation according to Davis & MacNeilage in 1998 (Oller 2000). Further consolidated control over movements of the legs, arms and digits is seemingly indicative of the subsequent speech development, though some experts argue of the relationships (Oller 2000, 115). Eilers & Oller (1994), Stoel-Gammon & Otomo (1986), Vinter (1987, 1994a, 1994b) concluded that hearing is vital feature in a child for speech development (Oller 2000). Hearing deficit then appears to deprive a deaf cleft lip and palate child early speech development as auditory capabilities allows hearing one’s own voice, as such, making the necessary adjustments in vocalizations (Oller 2000). Additionally, Siegel, Pick, & Garber (1984) cited that feedback or hearing one’s own voice help in the development of a child’s speech (Oller 2000). Another plausible argument is the fact that deaf children do not have the experience to hear sounds, thus, the greater potentials for imitating sounds are missed, which could be the fundamental base for vocalizations (Oller 2000; Lee, Harris, and Graham eds. 2003). Precise Medical surgery of cleft lip palate especially along the soft palate area then would likewise include the shielding of the auditory canals at the choanae resolving the problem of deafness, permitting occasions to hear sounds and echo the same in the bid to initiate verbal communication. Conclusion Cleft lip and palate may be complete or incomplete depending upon the surface tissues that failed to fuse during embryonic development affecting voice production after birth. This is usually due to the absence of connective tissues that serve as binders and bridges of cells. In the event that only the lip tissues or Orbicularis oris failed to fuse, cleft lip would result. Typically, this can be readily remedied with minor medical surgical process. The tissues will be sutured together closing the cleave part of the lip. Normal voice development would ensue as soon as the structural fusion is completed and healed, because air from the lungs can exert pressure on a close oral cavity. With the corresponding collaboration of the tongue, vibrations produced on the vocal folds may be manipulated to produce an audible voice. Practically, verbal communication would be appropriate because correct pronunciation of letters and words or articulation can already be done. In instances where orthodontic requirements are needed, this is to align some dentures that may be slightly affected by the defect. To some, this could be a minor problem, but, definitely this would affect speech. Thus proper medical attention should be given to the subject as well as some speech pathology assistance for vocalizations. On the other hand, in case the Orbicularis oris, the hard palate, and the soft palate failed to fuse, and the palatine tonsil is not formed, complete cleft lip and palate happen. In this case, speech production is nasal and loud with the failure to appropriately articulate the word or words that is typically understood to mean a thing or act. Additionally, the child with complete cleft lip and palate is deaf as the soft palate that separates the portion of the choanae and the oral cavity is not close. This cleave exposes the opening of the auditory tube to the oral cavity, dripping fluid from the ears resulting to subsequent ear infections and eventual hearing loss. Thus, the subject would be deaf unless repaired. Nevertheless, modern day medical surgical technology is capable of fusing the lips, hard palate, and soft palate together, thus, completely separating the nasal cavity from the oral cavity. This will likewise hugely put back the hearing capacity as the opening of the auditory tube is confined by the soft palate. And, with the advent of culturing tissues in vitro, it is probable also that a palatine tonsil may be sutured to the tip of the soft palate so that the aspiration of normal voice and speech will be met by the subject. Furthermore, the rise in the number of speech pathologist, orthodontist, and aesthetic surgeons broadly increases the chances of children with the congenital defect to be able to speak normally and proceed with normal verbal communications in a well modulated voice. Reference Baken, R. J. and Orlikoff, R. F. 2000. Clinical Measurement of Speech and Voice. London: Singular. Eliason, Michele J., and Lynn C. Richman. 1990. Language Development in Preschoolers with Cleft. Developmental Neuropsychology 6, no. 2: 173-182. http://www.questia.com/PM.qst?a=o&d=76973140. Emmorey, Karen. 2002. 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