Elimination of nasal tone of voice. Rhinolalia - causes, closed and open forms, as well as correction in children and adults Speech therapy exercises to eliminate nasal tint
Rhinolalia
forms of rhinolalia, elimination of rhinolalia, gymnastics of the soft palate, exercises for the cheeks, lips, tongue
Rhinolalia (from the Greek rhinos - nose, lalia - speech) is a violation of the timbre of the voice and sound pronunciation, caused by anatomical and physiological defects of the speech apparatus.
Rhinolalia in its manifestations differs from dyslalia by the presence of an altered nasalized (from the Latin paziz - nose) voice timbre.
With rhinolalia, the articulation of sounds and phonation differ significantly from the norm. With normal phonation, during the pronunciation of all speech sounds except nasal sounds, a person separates the nasopharyngeal and nasal cavities from the pharyngeal and oral ones. These cavities are separated by velopharyngeal closure, caused by contraction of the muscles of the soft palate, lateral and posterior walls of the pharynx. Simultaneously with the movement of the soft palate during phonation, thickening of the posterior wall of the pharynx (Passavan roller) occurs, which promotes contact of the posterior surface of the soft palate with the posterior wall of the pharynx.
During speech, the soft palate continuously lowers and rises to different heights depending on the sounds being spoken and the rate of speech. The strength of the velopharyngeal closure depends on the sounds being pronounced. It is smaller for vowels than for consonants. The weakest velopharyngeal closure is observed with the consonant “b”, the strongest with “c”, usually 6-7 times stronger than with “a”. During normal pronunciation of the nasal sounds m, m, n, n, the air stream freely penetrates into the space of the nasal resonator.
Depending on the nature of the dysfunction of the velopharyngeal closure, various forms of rhinolalia are distinguished.
Forms of rhinolalia and features of sound pronunciation
Open rhinolalia
With the open form of rhinolalia, oral sounds become nasal. The timbre of the vowels “i” and “u” changes most noticeably, during the articulation of which the oral cavity is most narrowed. The vowel “a” has the least nasal connotation, since when it is pronounced the oral cavity is wide open.
The timbre is significantly impaired when pronouncing consonants. When pronouncing sibilants and fricatives, a hoarse sound is added that occurs in the nasal cavity. Explosive “p”, “b”, “d”, “t”, “k” and “g” sound unclear, since the necessary air pressure is not generated in the oral cavity due to incomplete closure of the nasal cavity.
The air flow in the oral cavity is so weak that it is not sufficient to vibrate the tip of the tongue necessary to produce the sound “r”.
Diagnostics
To determine open rhinolalia, there are different methods of functional research. The simplest is the so-called Gutzmann test. The child is forced to alternately repeat the vowels “a” and “i”, while the nasal passages are either closed or opened. With the open form, there is a significant difference in the sound of these vowels. With the nose pinched, sounds, especially “i,” are muffled, and at the same time the speech therapist’s fingers feel a strong vibration on the wings of the nose.
You can use a phonendoscope. The examiner inserts one “olive” into his ear, the other into the child’s nose. When pronouncing vowels, especially "u" and "i", a strong hum is heard.
Functional open rhinolalia is caused by various reasons. It is explained by insufficient elevation of the soft palate during phonation in children with sluggish articulation.
One of the functional forms is “habitual” open rhinolalia. It is often observed after removal of adenoid growths or, less commonly, as a result of post-diphtheria paresis, due to prolonged restriction of the mobile soft palate.
A functional examination in the open form does not reveal any changes in the hard or soft palate. A sign of functional open rhinolalia is a more pronounced violation of the pronunciation of vowel sounds. With consonants, the velopharyngeal closure is good.
The prognosis for functional open rhinolalia is usually favorable. It disappears after phoniatric exercises, and disturbances in sound pronunciation are eliminated by the usual methods used for dyslalia.
Organic open rhinolalia can be acquired or congenital. Acquired open rhinolalia is formed with perforation of the hard and soft palate, with cicatricial changes, paresis and paralysis of the soft palate. The cause may be damage to the glossopharyngeal and vagus nerves, injuries, tumor pressure, etc.
The most common cause of congenital open rhinolalia is congenital cleft of the soft or hard palate, shortening of the soft palate.
Rhinolalia, caused by congenital clefts of the lip and palate, represents a serious problem for various branches of medicine and speech therapy. It is the subject of attention of dental surgeons, orthodontists, pediatric otolaryngologists, psychoneurologists and speech therapists. Clefts are adjacent to the most common and severe malformations.
The incidence of children born with clefts varies among different peoples, in different countries, and even in different regions of each country. A. A. Limberg (1964), summarizing information from the literature, notes that for every 600-1000 newborns, one child is born with a cleft lip and palate. Currently, the birth rate in different countries of children with congenital pathologies of the face and jaws ranges from 1 in 500 newborns to 1 in 2500, with a tendency to increase over the past 15 years.
Facial clefts are defects of complex etiology, i.e. multifactorial defects. Genetic and external factors or their combined action in the early period of embryo development play a role in their occurrence.
There are:
1. biological factors (influenza, mumps, rubella measles, toxoplasmosis, etc.);
2. chemical factors (pesticides, acids, etc.); endocrine diseases of the mother, mental trauma and occupational harm;
3. There is information about the effects of alcohol and smoking.
The critical period for nonfusion of the upper lip and palate is the 7-8th week of embryogenesis.
The presence of a congenital cleft lip or palate is a common symptom for many nosological forms of hereditary diseases. Genetic analysis shows that familial patterns of cleft lip and palate are quite rare. However, medical and genetic counseling of families for the purposes of diagnosis and prevention is of great importance. Currently, microsigns of cleft lips and palate have been identified in parents: a groove on the palate or uvula of the soft palate, a cleft uvula, an asymmetrical tip of the nose, an asymmetrical arrangement of the bases of the wings of the nose (N. I. Kasparova, 1981).
Children with congenital clefts have serious functional disorders (sucking, swallowing, external respiration, etc.), which reduce resistance to various diseases. They need systematic medical supervision and treatment. According to the state of mental development, children with clefts constitute a very heterogeneous group: children with normal mental development; with mental retardation; with mental retardation (of varying degrees). Some children have individual neurological microsigns: nystagmus, slight asymmetry of the palpebral fissures, nasolabial folds, increased tendon and peristal reflexes. In these cases, rhinolalia is complicated by early damage to the central nervous system. Much more often children experience functional disorders of the nervous system, pronounced psychogenic reactions to their defect, increased excitability, etc.
A characteristic feature of children with rhinolalia is a change in oral sensitivity in the oral cavity. Significant deviations in stereognosis in children with clefts in comparison with the norm were noted by M. Edwards. The reason is dysfunction of the sensorimotor pathways, caused by inadequate feeding conditions in infancy. Pathological features of the structure and activity of the speech apparatus cause various deviations in the development of not only the sound side of speech; various structural components of speech suffer to varying degrees.
Closed rhinolalia
Closed rhinolalia occurs when physiological nasal resonance is reduced during the production of speech sounds. The strongest resonance is for the nasal m, m", n, n". When pronounced normally, the nasopharyngeal valve remains open and air enters directly into the nasal cavity. If there is no nasal resonance for nasal sounds, they sound like oral sounds b, b" d, d". In speech, the opposition of sounds on the basis of nasal - non-nasal disappears, which affects its intelligibility. The sound of vowel sounds also changes due to the deafening of individual tones in the nasopharyngeal and nasal cavities. In this case, vowel sounds acquire an unnatural connotation in speech.
The cause of the closed form is most often organic changes in the nasal space or functional disorders of the velopharyngeal closure. Organic changes are caused by painful phenomena, as a result of which nasal breathing becomes difficult.
M. Zeeman distinguishes two types of closed rhinolalia (rhinophonia): anterior closed - with obstruction of the nasal cavities and posterior closed - with a decrease in the nasopharyngeal cavity.
Anterior closed rhinolalia is observed with chronic hypertrophy of the nasal mucosa, mainly of the posterior inferior concha; for polyps in the nasal cavity; with a deviated nasal septum and tumors of the nasal cavity.
Posterior closed rhinolalia in children can be a consequence of adenoid growths, less often nasopharyngeal polyps, fibroids or other nasopharyngeal tumors.
Functional closed rhinolalia is often observed in children, but is not always correctly recognized. It occurs with good patency of the nasal cavity and undisturbed nasal breathing. However, the timbre of nasal and vowel sounds may be more disturbed than with organic forms.
During phonation and when pronouncing nasal sounds, the soft palate rises strongly and blocks access to sound waves to the nasopharynx. This phenomenon is more often observed in neurotic disorders in children. With organic closed rhinolalia, first of all, the causes of obstruction in the nasal cavity must be eliminated. As soon as correct nasal breathing occurs, the defect disappears. If, after eliminating the obstruction (for example, after adenotomy), rhinolalia continues to exist, resort to the same exercises as for functional disorders.
Mixed rhinolalia
Some authors (M. Zeeman, A. Mitronovich-Modrzejewska) identify mixed rhinolalia - a speech condition characterized by reduced nasal resonance when pronouncing nasal sounds and the presence of a nasal timbre (nasalized voice). The cause is a combination of nasal obstruction and insufficiency of the velopharyngeal contact of functional and organic origin. The most typical are combinations of a shortened soft palate, its submucosal cleft and adenoid growths, which in such cases serve as an obstacle to air leakage through the nasal passages during the pronunciation of oral sounds.
The state of speech may worsen after adenotomy, as velopharyngeal insufficiency occurs and signs of open rhinolalia appear. In this regard, the speech therapist should carefully examine the structure and function of the soft palate, determine which form of rhinolalia (open or closed) most disrupts the timbre of speech, discuss with the doctor the need to eliminate nasal obstruction and warn parents about the possibility of worsening the timbre of the voice. After surgery, correction techniques developed for open rhinolalia are used.
It is known that with congenital cleft palate, the voice, in addition to excessive open nasalization, is weak, monotonous, non-flying, muffled, and compressed. M. Zeeman even identified this voice disorder as an independent one and called it palatophonia.
However, attention is drawn to the fact that the voice of children with cleft palate in the first year of life does not differ from the voice with a normal structure of the upper jaw. In the pre-speech period, these children scream, cry, and walk in a normal child's voice.
Subsequently, until about seven years of age, children with congenital cleft palates speak (both in the absence of plastic surgery and often after it) in a voice with a nasal tint, sometimes quiet due to behavioral characteristics, but in other qualities clearly not different from normal. An electroglottographic study at this age confirms the normal motor function of the larynx, and myography confirms the normal reaction of the pharyngeal muscles to a stimulus, even with extensive defects of the palate.
After seven years, the voice of children with congenital cleft palates begins to deteriorate: strength decreases, hoarseness and exhaustion appear, and the expansion of its range stops. Myography reveals an asymmetrical reaction of the pharyngeal muscles, thinning of the mucous membrane and a decrease in the pharyngeal reflex are visually observed, and changes appear on the electroglotogram indicating uneven functioning of the right and left vocal folds, i.e., all signs of a disorder of the motor function of the voice-producing apparatus, which is permanent is formed and consolidated by adolescence.
Three main causes of voice pathology in congenital cleft palate can be identified.
This is, firstly, a violation of the velopharyngeal closure mechanism. It is known that due to the close functional connection of the soft palate and the larynx, the slightest tension and movement of the muscles of the velum palate causes a corresponding tension and motor reaction in the larynx. With cleft palate, the muscles that lift and stretch it, instead of being synergists, work as antagonists. At the same time, due to a decrease in the functional load, a degenerative process occurs in them, as in the muscles of the pharynx. The pathological mechanism of closure is enhanced by the congenital asymmetry of the facial skeleton and laryngeal cavities, which is clearly visible on X-rays and tomograms in congenital cleft palate. Anatomical defect of the palate and pharynx leads to a functional disorder of the vocal apparatus.
Secondly, this is the incorrect formation of a number of voiced consonants in rhinolalia in the laryngeal way, when closure is carried out at the level of the larynx and air friction on the edges of the vocal folds is voiced. In this case, the larynx takes on the additional function of an articulator, which, of course, does not remain indifferent to the vocal folds.
Thirdly, the development of the voice is influenced by the behavioral characteristics of persons with rhinophony and rhinolalia. Ashamed of their defective speech, adolescents and adults often speak in a quiet voice and limit verbal communication as much as possible in the microenvironment, thereby reducing the opportunities for developing the strength of their voice and expanding its range.
Features of speech breathing in persons with cleft palate are expressed in increased breathing, in the predominance of the superficial clavicular type of breathing and in shortening of phonation exhalation, which is caused by leakage of air flow into the nasal cavity. The leakage rate depends on the shape of the crevice and can exceed 30%. The duration of exhalation is equal to inhalation. There is no differentiated oral and nasal exhalation.
Speech disorders with rhinolalia
With rhinolalia, speech develops late (the first words appear by two years and much later) and has qualitative features. Impressive speech develops relatively normally, while expressive speech undergoes some qualitative changes.
First of all, it should be noted that the patients’ speech is extremely slurred. The words and phrases that appear in them are difficult to understand for those around them, since the sounds that are formed are unique in articulation and sound. Due to the defective position of the tongue in the oral cavity, consonant sounds are formed mainly due to changes in the position of the tip of the tongue (with little participation of the tongue root in articulation) with excessive activation of the facial muscles.
These changes in the position of the tip of the tongue are relatively constant and correlate with the articulation of certain sounds. Pronunciation of some consonant sounds is particularly difficult for patients. Thus, they cannot implement the necessary barrier at the upper teeth and alveoli to pronounce the sounds of the upper position: l, t, d, ch, sh, shch, zh, r; at the lower incisors to pronounce sounds s, z, c with simultaneous oral exhalation; Therefore, whistling and hissing sounds in rhinolalics acquire a peculiar sound. The sounds k and g are either absent or replaced by a characteristic explosion. Vowel sounds are pronounced with the tongue pulled back and air exhaled through the nose and are characterized by sluggish labial articulation.
Thus, vowels and consonants are formed with a strong nasal connotation. Their articulation is often significantly changed, and the sounds are not clearly differentiated from each other. For the patient himself, such articulomes serve as kineme, i.e., a motor characteristic of a certain sound, and in his speech they perform a meaning-distinguishing function, which allows them to be used for speech communication.
All sounds pronounced by the patient are perceived by ear as defective. Their common characteristic for the listener is snoring sounds with a nasal tint. In this case, unvoiced sounds are perceived as close to the sound “x”, voiced sounds - to the fricative “g”; Of these, the labial and labiodental are close to the sound “m”, and the anterior lingual are close to the sound “n” with a slight modification of the sound.
Sometimes articulomes in the speech of a rhinolalic are very close to normal, and their pronunciation, despite this, is perceived by ear as defective (snoring), since speech breathing is impaired, and, in addition, excessive tension of the facial muscles occurs, which in turn affects articulation and sound effect.
Thus, sound pronunciation in rhinolalia is completely affected. Patients usually lack independent awareness of their speech defect or their sensitivity to it is reduced. Listening to a recording of their speech stimulates patients to take serious speech therapy classes.
Thus, in the structure of speech activity in rhinolalia, the defect in the phonetic-phonemic structure of speech is the leading element of the disorder, and the primary one is a violation of the phonetic structure of speech. This primary defect leaves some imprint on the formation of the lexico-grammatical structure of speech, but deep qualitative changes usually occur only when rhinolalia is combined with other speech disorders.
In the literature there are indications of the uniqueness of the formation of written speech in rhinolalia. Without dwelling separately on the analysis of the causes of writing defects in rhinolali, it can be pointed out that the proposed method of working to prevent writing disorders and excludes them in cases of early speech therapy assistance (preschool education).
Speech deficiency in rhinolalia affects the formation of all mental functions of the patient and, first of all, the development of personality. The originality of its development is determined by the unfavorable living conditions in a group for rhinolalic.
Impaired speech as a means of communication makes it difficult for patients to behave in a group. Often their communication with the team is one-sided, and the result of communication traumatizes the children. They develop isolation, shyness, and irritability. Their activity is in a more favorable state, since these patients are often intellectually complete (if rhinolalia manifests itself in its pure form).
Purposeful work to overcome a speech defect contributes to the formation of positive character traits and erases the development of higher mental functions. Follow-up information presented in the literature and observations show that the majority of children with rhinolalia are capable of a high degree of compensation for the defect and rehabilitation of functions.
So, congenital clefts negatively affect the formation of the child’s body and the development of higher mental functions. Patients find unique ways to compensate for the defect, resulting in the formation of incorrect interchangeability of the muscles of the articulatory apparatus. This is the cause of the primary disorder - a violation of the phonetic design of speech - and acts as a leading disorder in the structure of the defect. This disorder entails a number of secondary disturbances in the speech and mental status of the patient. However, this group of patients has great adaptive and compensatory capabilities for the rehabilitation of impaired functions.
In oral speech, impoverishment and abnormal conditions for the prelinguistic development of children with rhinolalia are noted. Due to a violation of speech motor periphery, the child is deprived of intense babbling and articulatory “game”, thereby impoverishing the stage of preparatory tuning of the speech apparatus. The most typical babbling sounds “p”, “b”, “t”, “d” are articulated by the child silently or very quietly due to the leakage of air through the nasal passages and thus do not receive auditory reinforcement in children. Not only the articulation of sounds suffers, but also the development of simple elements of speech. There is a late onset of speech, a significant time interval between the appearance of the first syllables, words and phrases already in the early period, which is sensitive for the formation of not only its sound, but also its semantic content, i.e., a distorted path of development of speech as a whole begins. To the greatest extent, the defect manifests itself in a violation of its phonetic side.
As a result of peripheral insufficiency of the articulatory apparatus, adaptive (compensatory) changes in the structure of the articulation organs are formed when pronouncing sounds; high elevation of the root of the tongue and its shift to the posterior zone of the oral cavity; insufficient participation of the lips when pronouncing labialized vowels, labiolabial and labiodental consonants; excessive involvement of the root of the tongue and larynx; tension of facial muscles.
The most significant manifestations of defective formation of oral speech are violations of all oral speech sounds due to the connection of nasal D and changes in the aerodynamic conditions of phonation. The sounds become nasal, that is, the characteristic tone of the consonants changes. Pharyngealization, i.e. additional articulation due to tension in the walls of the pharynx, occurs as a compensatory means.
There are also phenomena of additional articulation in the laryngeal cavity, which gives speech a peculiar “clicking” sound.
Many other more specific defects are revealed. For example:
1. lowering the initial consonant (“ak” - “so”, “am” - “there”);
2. neutralization of dental sounds according to the method of formation;
3. replacing plosives with fricatives;
4. whistling background when pronouncing hissing sounds or vice versa (“ssh” or “shs”);
5. absence of vibrant r or replacement with the sound s during strong exhalation;
6. adding additional noise to nasal sounds (hissing, whistling, aspiration, snoring, throatiness, etc.);
7. moving articulation to more posterior zones (the influence of the high position of the root of the tongue and the small participation of the lips in articulation). For example, the sound "s" is replaced by the sound "f" without changing the method of articulation. Characteristic is a decrease in the intelligibility of sounds in a combination of consonants in the final position.
The relationship between nasalization of speech and distortions in the articulation of individual sounds is very diverse.
It is impossible to establish a direct correspondence between the size of the palatal defect and the degree of speech distortion. The compensatory techniques that children use to produce sounds are too diverse. Much also depends on the ratio of the resonating cavities and on the variety of their configuration features of the oral and nasal cavities. There are factors that are less specific, but also influence the degree of intelligibility of sound pronunciation (age, individual psychological properties, socio-psychological, etc.). The speech of a child with rhinolalia is generally unintelligible.
M. Momescu and E. Alex showed that the spoken speech of children with cleft palate contains only 50% of the information compared to the norm; the ability to transmit a child’s speech message is halved. This causes serious communication difficulties. Thus, the mechanism of disorders in open rhinolalia is determined by the following:
1) the absence of a velopharyngeal seal and, as a result, a violation of the opposition of sounds on the basis of oronasal;
2) a change in the place and method of articulation of most sounds due to defects of the hard and soft palate, flaccidity of the tip of the tongue, lips, retraction of the tongue deeper into the oral cavity, high position of the root of the tongue, participation in the articulation of the muscles of the pharynx and larynx.
Peculiarities of oral speech of children with rhinolalia in many cases are the cause of deviations in the formation of other speech processes.
Written speech
The pronunciation features of children with rhinolalia lead to distortion and immaturity of the phonetic system of the language. Therefore, the sound images accumulated in their speech consciousness are incomplete and are not dissected for the formation of correct writing. Secondarily determined features of the perception of speech sounds are the main obstacle to mastering correct writing.
The connection between writing disorders and defects in the articulatory apparatus has various manifestations. If by the time of training a child with rhinolalia has mastered intelligible speech, can clearly pronounce most of the sounds of his native language, and only a slight nasal tone remains in his speech, then the development of sound analysis necessary for learning to read and write is proceeding successfully. However, as soon as a child with rhinolalia experiences additional obstacles to normal speech development, specific errors in writing appear. Late onset of speech, a long absence of speech therapy assistance, without which the child continues to pronounce obscure, distorted words, lack of speech practice, and in some cases reduced mental activity affect all of his speech activity.
Dysgraphic errors that are observed in the written work of children with cleft palates are varied.
Specific for rhinolalia are replacements of “p”, “b” with “m”, “t”; "d" to "n" and reverse replacements "n" - "d"; “t”, “m - “b”, “p” are due to the lack of phonological opposition of the corresponding sounds in oral speech. For example: “will come” - “will receive”, “gave” - “cash”, “lily of the valley” - “lannysh” , "ladnysh", "og" - "fire", etc.
Omissions, substitutions, and the use of extra vowels are identified: “in the canopy” - “in the blue”, “kreltsa” - “porch”, “gribimi” - “mushrooms”, “gulucote” - “dovecote”, “prshel” - “came” .
Substitutions and mixtures of hissing and whistling “zelezo” - “iron”, “whirled” - “whirled” are common.
Difficulties in using affricates are noted. The sound “ch” in writing is replaced by “sh”, “s” or “zh”; “sch” to “ch”: “hide” - “hide”, “shchulan” - “closet”, “shitala” - “read”, “serez” - “through”.
The sound "ts" is replaced with "s": "skvores" - "starling".
Mixtures of voiced and voiceless consonants are characteristic: “correct” - “correct”, “in the portfolio” - “in the portfolio”.
It is not uncommon to make mistakes by missing one letter from the sequence: “rasvel” - “bloomed”, “konatu” - “room”.
The sound “l” is replaced by “r”, “r” by “l”: “cooked” - “failed”, “swimmed up” - “swam”.
The degree of writing impairment depends on a number of factors: the depth of the defect in the articulatory apparatus, the characteristics of the child’s personal and compensatory abilities, the nature and timing of speech therapy, and the influence of the speech environment.
It is necessary to carry out special work, including the development of phonemic perception with a simultaneous impact on the pronunciation side of speech. Correction of speech disorders in children with rhinolalia is carried out differentially depending on age, the state of the peripheral part of the articulatory apparatus and the characteristics of speech development in general.
The main differentiating indicator for placing children in speech therapy institutions is the development of speech processes. Preschool children with phonetic speech disorders are provided with speech therapy assistance on an outpatient basis, in a children's clinic or in a hospital (in the postoperative period). Children with underdevelopment of other speech processes are enrolled in specialized kindergartens in groups for children with phonetic-phonemic or general speech underdevelopment.
School-age children with severe phonemic perception disorders receive help at speech centers at secondary schools. However, they constitute a specific group due to the severity and persistence of the primary defect and the severity of the writing impairment.
Therefore, correctional interventions in special schools are often more effective for them.
School-age children with rhinolalia, who have general speech underdevelopment, are characterized by insufficient development of vocabulary and grammatical structure.
Its causes are different: narrowing of social and speech contacts of children due to a gross defect in sound speech, late onset, complication of the main defect with manifestations of dysarthria or alalia.
Speech errors reflect a low level of mastery of language patterns, a violation of lexical and syntactic compatibility, and a violation of the norms of the literary language. They are due, first of all, to the small amount of speech practice. The children's vocabulary is not precise enough in its use, with a limited number of words denoting abstract and general concepts. This explains the stereotypical nature of their speech, the replacement of words with similar meanings.
In written speech, typical cases are the incorrect use of prepositions, conjunctions, particles, errors in case endings, i.e. manifestations of agrammatism in writing. Substitutions and omissions of prepositions, merging of prepositions with nouns and pronouns, and incorrect division of sentences are common.
Elimination of rhinolalia
The effectiveness of speech therapy to eliminate rhinolalia depends on the condition of the nasopharynx and the age of the child. An important factor is the child’s ability to distinguish a nasal voice from a normal one.
Speech therapy sessions with the child must begin in the preoperative period in order to prevent the occurrence of serious changes in the functioning of the speech organs. At this stage, the activity of the soft palate is prepared, the position of the root of the tongue is normalized, the muscular activity of the lips is enhanced, and directed oral exhalation is produced. All this taken together creates favorable conditions for increasing the effectiveness of the operation and subsequent correction. 15-20 days after surgery, special exercises are repeated; but now the main goal of the classes is to develop the mobility of the soft palate.
The study of the speech activity of children suffering from rhinolalia shows that defective anatomical and physiological conditions of speech formation, limited motor component of speech lead not only to the abnormal development of its sound side, but in some cases to a deeper systemic disorder of all its components.
As the child ages, the indicators of speech development worsen (compared to the indicators of normally speaking children), the structure of the defect is complicated by impairment of various forms of written speech.
Early correction of deviations in speech development in children with rhinolalia has an extremely important social, psychological and pedagogical significance for normalizing speech, preventing difficulties in learning and choosing a profession.
Parents should be fully aware that surgical treatment does not ensure normal speech, but only creates full-fledged anatomical and physiological conditions for the development of correct pronunciation.
It is also necessary to encourage parents to consolidate all achieved results every day.
It often happens that the somatic weakness of a child with rhinolalia, the presence of a speech defect causes constant anxiety in parents, anxiety about any reason, the need for excessive care of the baby, and distrust in his capabilities.
Your child is not alone:
birth rate and causes
Congenital clefts of the upper lip and palate - this is how the developmental defects, formerly known as “cleft lip” and “cleft palate,” should be called. Today, more than ever in the past, humanity is experiencing the consequences of adverse factors on itself and its children. Their influence on the developing fetus is much more dangerous than on an adult. That is why in Russia, 1 out of 500-1000 newborns are born with a cleft lip and palate. In 75% of cases, facial clefts are an isolated fetal malformation. In this case, as a rule, in a family of healthy parents, a child with a cleft lip and palate appeared for the first time.
Why? The reasons are varied. It is usually impossible to establish the exact cause in each specific case. Known provoking factors are presented today in two groups:
1. Environmental factors.
Intrauterine infections. The most dangerous are cytomegalovirus infection, herpes type I and II, toxoplasmosis, rubella, influenza, viral hepatitis, chlamydia, syphilis, mycoplasmosis and other sexually transmitted infections, especially in the acute phase.
Chemical (aniline dyes, petroleum products, synthetic rubber, substances used in the production of plastics, viscose fibers) and physical agents (ionizing radiation, high temperature of industrial premises).
Medicines (folic acid antagonists, vitamin A, cortisone, barbiturates, cytostatics). Their teratogenic effect (causing malformations in the fetus) has been proven.
However, there are other drugs about which we have insufficient information. Alcohol, smoking and drugs. Future parents often do not think about their harmful effects on the embryo. However, it has been proven that the risk of having a child with a cleft lip and palate in a smoking mother is 25% higher than in a non-smoking mother.
Old age of parents, unfavorable socio-economic conditions.
2. Hereditary factors.
The risk of having a child with a cleft lip and palate among the population is quite low (~0.002%). However, if one of the parents or a previous child has this pathology, the risk of having a second baby with this disease is ~2-5%. The risk of recurrence of the pathology increases significantly (up to ~13-14%) if a cleft lip and palate is diagnosed in two family members (both parents or one parent and one child) and is ~20-50% in the rare case when this defect occurred in both parents of the baby and one of their children.
Particular attention should be paid to hereditary syndromes. Hereditary syndromes are diseases represented by a set of certain developmental defects transmitted from generation to generation. The number of syndromes that include cleft lip and palate is quite large - about 300. That is why, when a child is born with any type of this pathology, consultation with a geneticist is necessary. Parents have the right to receive reliable information about the prospects for the child’s development, the possible outcomes of subsequent pregnancies in a particular marriage and preventive measures.
Important: a combination of a number of signs - a transverse cleft of the face, parotid appendages and a malformation of the auricle, OR a congenital cleft of the upper lip and palate and congenital fistulas/cysts of the lower lip - indicates the presence of a hereditary syndrome in the baby. In this case, consultation with a geneticist is mandatory!
Prenatal diagnosis and prevention of rhinolalia. My recommendations for future parents
The most reliable information about the health status of a developing baby can be obtained by performing an ultrasound diagnostic examination. By the end of the 12th week of pregnancy, the formation of the baby’s face is almost completely completed, so this period (11-12th week of pregnancy) is the optimal time for performing an ultrasound.
Hereditary syndromic pathology in the fetus can be excluded by studying the chromosome set of the fetus as a result of chorionic villus biopsy (11-12th week) or studying amniotic fluid through amniocentesis (16th week of pregnancy). These manipulations are carried out according to the recommendations of an obstetrician-gynecologist and geneticist and have strict indications.
Note! The purpose of an ultrasound examination is to identify fetal malformations and features of the course of pregnancy. The 11-12th and 23-24th weeks of pregnancy are the optimal times for it. Today, this study can be performed in three-dimensional mode, which can significantly increase its effectiveness.
A general way to prevent the birth of a child with any developmental defects is family planning, which is based on a number of certain conditions:
The favorable age for a woman to give birth to a child is 18-35 years.
Treatment of all sexually transmitted infectious diseases before pregnancy - for both spouses.
Health improvement for spouses before pregnancy.
Avoiding bad habits before and during pregnancy.
Elimination or limitation of harmful production factors, reasonable use of medications during pregnancy.
Careful medical monitoring during pregnancy with the necessary diagnostic examination.
Taking vitamins with a high content of folic acid for 3 months before conception and during the first trimester of pregnancy.
Speech therapy training
Speech assessment
At the age of 2.5 - 3 years, a speech therapist who specializes in teaching children with congenital cleft palates can assess the state of the child’s speech. During a standard examination, the speech therapist determines: the type of physiological breathing, phonation exhalation, and the position of the tongue in the oral cavity. To assess the method and place of sound formation, speech therapy tests available for a child of this age are used, based on the pronunciation of certain words. It is their sound set (P, B, T, K, A, O, I, U) that allows us to determine the presence of compensatory grimaces and assess the severity of nasalism (hypernasalization) and nasal emission (air leakage). Thus, in the presence of speech pathology, its clear diagnosis can be carried out. The diagnosis was made: rhinophonia - indicates a speech disorder, characterized by an increase in the nasal resonance of the voice, rhinolalia - including, in addition to the above, incorrect sound formation.
In some cases, when older patients with speech disorders (previously operated on in other medical institutions and having experience in speech therapy training) come to the clinic, in addition to speech therapy examination, nasopharyngoscopy is performed. This is a method for objectively assessing the functional state of all structures of the velopharyngeal ring, which makes it possible to diagnose velopharyngeal insufficiency and determine the tactics for further treatment of the child.
Stages and methods of speech therapy training
Speech therapy training begins at the age of 2.5 - 3 - 3.5 years when the child is prepared and able to concentrate his attention during the lesson. The course of speech therapy training includes daily one- or two-time sessions with a highly qualified speech therapist in a clinic or hospital setting. Classes are carried out according to the methodology of speech therapy training.
At the initial stage, the speech therapist develops an individual approach to each child, during conversations he gets an idea of the range of his interests, personality traits, establishes personal contact, indicates the need for speech therapy classes and confidence in their results. It is especially important that the child hears his own sound substitutions and perceives the need to reproduce them correctly. Articulation gymnastics is carried out simultaneously or sequentially with psychotherapeutic sessions. Its main goal is to activate and restore the correct functioning of all components of the articulatory apparatus (upper and lower jaws, tongue, neck muscles, larynx and vocal cords) and exclude compensatory mechanisms from the process of sound formation. An important section of articulatory gymnastics is the activation of the soft palate through active gymnastics. A special place in the classes is given to breathing exercises to obtain a long oral exhalation under the control of the movements of the diaphragm and abdominal press.
After adequate preparation of the articulatory apparatus, voice exercises begin: vocal gymnastics, singing songs, using games that develop the pitch of the voice. During speech therapy classes, work is done on the production of sounds and then their automation at the level of syllables-words-sentences-phrases-coherent speech, the strength and timbre of the voice develops.
Note: Optimal is the active participation of parents during speech therapy classes; this will allow, during the period between training courses, not to lose the skills acquired by the child, repeat a significant part of the exercises at home and control the child’s pronunciation.
The duration of one course of speech therapy training is at least 3 weeks, at the time of completion of which the effectiveness of training and the dynamics of speech restoration are assessed. The full training cycle includes 3-4 full courses, after which nasopharyngoscopy is performed. In the absence of positive dynamics during speech therapy training, in accordance with clinical data and the results of nasopharyngoscopy, the maxillofacial surgeon and speech therapist of the center decide on the possibility of continuing speech therapy training or on the need to eliminate velopharyngeal insufficiency surgically and determine the optimal method of surgical intervention.
Cautions for Parents
Note: A variety of teaching methods have been proposed for children with various speech disorders. However, do not try to use these techniques on your own! The best option for solving your baby’s problems is to consult a highly qualified specialist in this field, who will adequately assess the state of your child’s speech and determine when and how to work with your baby, which exercises should be done first, and which should not be used at all!
Early and correct determination of the tactics of speech therapy training for your child is at least half the success in the difficult process of restoring his speech.
The formation of phonetically correct speech in preschool children with a congenital cleft palate is aimed at solving several interrelated problems:
1) normalization of “oral exhalation,” i.e., the production of a long-lasting oral stream when pronouncing all speech sounds, except nasal ones;
2) development of correct articulation of all speech sounds;
3) elimination of the nasal tone of the voice;
4) developing the skills of differentiating sounds in order to prevent defects in sound analysis;
5) normalization of the prosodic aspect of speech;
6) automation of acquired skills in free speech communication.
Solving these specific problems is possible by taking into account the patterns of mastering correct pronunciation skills.
When correcting the sound aspect of speech, the acquisition of correct sound pronunciation skills goes through several stages.
The first stage - the stage of "pre-speech" exercises - includes the following types of work:
1) breathing exercises;
2) articulation gymnastics;
3) articulation of isolated sounds or quasi-articulation (since isolated pronunciation of sounds is atypical for speech activity);
4) syllabic exercises.
At this stage, motor skills are mainly trained on the basis of initial unconditioned reflex movements.
The second stage is the stage of differentiation of sounds, i.e., the education of phonemic representations based on motor (kinesthetic) images of speech sounds.
The third stage is the stage of integration, i.e. learning the positional changes of sounds in a coherent utterance.
The fourth stage is the stage of automation, that is, the transformation of correct pronunciation into normative, so familiar that it does not require special control on the part of the child himself and the speech therapist.
All stages of sound system acquisition are ensured by two categories of factors:
1) unconscious (through listening and reproduction);
2) conscious (through the assimilation of articulatory patterns and phonological characteristics of sounds).
The participation of these factors in the acquisition of the sound system varies depending on the age of the child and the stage of correction.
In preschool children, imitation plays a significant role, but elements of conscious assimilation must be present. This is due to the fact that the restructuring of a strong pathological skill of nasal pronunciation is impossible without activating all the child’s personal qualities, focusing on correcting the defect and without consciously assimilating new acoustic and motor stereotypes of speech sounds. Corrective tasks have a certain difference depending on whether plastic surgery has been performed to close cleft or not, although basic types of exercises are used both preoperatively and postoperatively.
Before the operation, the following tasks are solved:
1) release of facial muscles from compensatory movements;
2) preparation of the correct pronunciation of vowel sounds;
3) preparation of correct articulation of consonant sounds accessible to the child.
After surgery, correction tasks become much more complicated:
1) development of mobility of the soft palate;
2) elimination of incorrect arrangement of articulation organs when pronouncing sounds;
3) preparation of the pronunciation of all speech sounds without nasal connotation (with the exception of nasal sounds).
The following types of work are specific for the postoperative period:
a) massage of the soft palate;
b) gymnastics of the soft palate and the back wall of the pharynx;
c) articulation gymnastics;
d) voice exercises.
The main goal of these exercises is to:
- increase the strength and duration of the air stream exhaled through the mouth;
- improve the activity of articulatory muscles;
- develop control over the functioning of the velopharyngeal seal.
The main purpose of soft palate massage is to knead scar tissue.
Massage should be carried out before meals, in compliance with hygienic requirements. It is carried out as follows. Stroking movements are made along the suture line back and forth to the border of the hard and soft palate, as well as left and right along the border of the hard and soft palate. You can alternate stroking movements with intermittent pressing ones. Light pressure on the soft palate when pronouncing the sound “a” is also useful. The mouth should be wide open.
Gymnastics of the soft palate
1. Swallowing water or simulating swallowing movements. Children are offered to drink from a small glass or bottle. You can drip water from a pipette - a few drops at a time. Swallowing water in small portions causes the highest rise of the soft palate. A large number of successive swallowing movements lengthens the time during which the soft palate is in the upward position.
2. Yawning with your mouth open.
3. Gargling with warm water in small portions.
4. Coughing. This is a very useful exercise, since coughing causes a vigorous contraction of the muscles of the back of the throat. When coughing, a complete closure occurs between the nasal and oral cavities. By touching the larynx under the chin with your hand, the child can feel the palate rise.
5. The child is trained to cough voluntarily on one exhalation from 2-3 repetitions to more. During the exercise, the palate should remain closed with the back wall of the pharynx, and the air should be directed through the oral cavity. It is advisable for the child to cough with his tongue hanging out for the first time. Then coughing is introduced with arbitrary pauses, during which the child is required to maintain the closure of the palate with the back wall of the pharynx. By performing this exercise, children master the ability to actively lift the soft palate and direct the air stream through the mouth.
6. Clear, energetic, exaggerated pronunciation of vowel sounds in a high tone of voice. At the same time, the resonance in the oral cavity increases and the nasal tint decreases. First, the abrupt pronunciation of the vowel sounds “a”, “e” is trained, then “o”, “u” with exaggerated articulation.
7. Next, they gradually move on to clearly pronouncing the sound series “a”, “e”, “u”, “o” in different alternations. In this case, the articulatory pattern changes, but exaggerated oral exhalation remains. When this skill is strengthened, they move on to smoothly pronouncing sounds. For example: a, uh, o, y_______, a, y, o, uh_______.
8. Pauses between sounds increase to 1-3 s, but the elevation of the soft palate, in which the passage to the nasal cavity is closed, must be maintained.
9. The exercises described above give positive results in the preoperative period and after surgery. They should be carried out continuously over a long period of time. Systematic exercises in the preoperative period prepare the child for surgery and reduce the time required for subsequent correctional work.
10. To develop correct sonorous speech, it is necessary to work on correct breathing. It is known that rhinolalics have a very short, wasteful exhalation, in which the air comes out through the mouth and nasal passages. To develop the correct oral air stream, special exercises are performed in which inhalation and exhalation through the nose alternate with inhalation and exhalation through the mouth, for example: inhalation through the nose - exhalation through the mouth; inhale - exhale through the nose; inhale - exhale through the mouth.
With the systematic use of these exercises, the child begins to feel the difference in the direction of the air stream and learns to direct it correctly. This also helps to develop the correct kinesthetic sensations of movements of the soft palate.
It is very important to constantly monitor your child while performing these exercises, since at first it may be difficult for him to feel air leaking through the nasal passages.
Control techniques are different: a mirror, cotton wool, or strips of thin paper are placed at the nasal passages.
Blowing exercises also contribute to the development of the correct air stream. They need to be carried out in the form of a game, introducing elements of competition. Some of the toys are made by children themselves with the help of their parents. These are butterflies, pinwheels, flowers, panicles, made of paper or fabric. You can use strips of paper attached to wooden sticks, cotton balls on strings, light paper figures of acrobatics, etc. Such toys should have a specific purpose and be used only in classes on teaching correct speech.
Many parents make the mistake of buying balloons and accordions, inspired by the advice of a speech therapist, and giving them to their child for constant use. Children are not always able to inflate a balloon without preparatory exercises and often cannot play the harmonica because they do not have sufficient force to exhale through the mouth. Having failed, the child becomes disappointed in the toy and never returns to it.
Therefore, you need to start with easy, accessible exercises that give a clear effect. For example, children can blow out a candle first from a distance of 15-20 cm, then from a further distance. A child with weak oral exhalation may blow the cotton wool from his palm. If this fails, you can close his nostrils so that he feels the correct direction of the air stream. Then the nasal passages are gradually freed. This technique is often useful: light lumps of cotton wool (unpressed) are inserted into the nasal passages. If the air is mistakenly directed into the nose, they pop out and the child becomes convinced that his actions were wrong.
You can also blow on light plastic toys floating in water. A good exercise is to blow through a straw into a bottle of water. At the beginning of the lesson, the diameter of the tube should be 5-6 mm, at the end - 2-3 mm. As the water blows, it begins to bubble, which captivates small children. By looking at the “storm” in the water, you can easily estimate the strength of the exhalation and its duration. It is necessary to show the child that the exhalation should be smooth and long. It is good to mark the time of “seething” on an hourglass.
You can invite children to blow on balls or pencils lying on a smooth surface so that they roll. You can organize a game of soap bubbles. There are a lot of similar exercises. The more difficult of them is playing wind instruments. The speech therapist must keep in mind that breathing exercises quickly tire the child (they can cause dizziness), so they must be alternated with others.
At the same time, children are given a series of exercises, the main goal of which is to normalize speech motor skills.
It is known that children with rhinolalia develop pathological articulation features due to anatomical and physiological conditions.
Features of articulation are as follows:
1) high elevation of the tongue and its displacement deep into the oral cavity;
2) insufficient labial articulation;
3) excessive participation of the root of the tongue and larynx in the pronunciation of sounds.
Elimination of these articulation features is an important link in the correction of the defect. This is achieved through so-called articulatory gymnastics exercises that develop the lips, cheeks, and tongue.
Exercises for cheeks and lips:
1) inflating both cheeks at the same time;
2) puffing out the cheeks alternately;
3) retraction of the cheeks into the oral cavity between the teeth;
4) sucking movements - closed lips are pulled forward with the proboscis, then return to their normal position (jaws are closed);
5) grin: lips stretch strongly to the sides, exposing both rows of teeth up and down;
6) “proboscis” followed by a grin with clenched jaws;
7) grin with opening and closing of the mouth, closing of the lips;
8) stretching the lips with a wide funnel with the jaws open;
9) stretching the lips with a narrow funnel (imitation of whistling);
10) retraction of the lips into the mouth, pressing tightly against the teeth with the jaws wide open;
11) imitation of rinsing teeth (the air presses heavily on the lips);
12) lip vibration;
13) movement of the lips with the proboscis left and right;
14) rotational movements of the lips with the proboscis;
15) strong puffing of the cheeks (air is retained in the oral cavity by the lips).
Tongue exercises:
1) sticking out the tongue with a shovel;
2) sticking out the tongue with a sting;
3) protruding the flattened and pointed tongue alternately;
4) turning the strongly protruding tongue left and right;
5) raising and lowering the back of the tongue - the tip of the tongue rests on the lower gum, and the root either rises or falls;
6) suction of the back of the tongue to the palate, first with the jaws closed, and then with the jaws open;
7) the protruding wide tongue closes with the upper lip, and then retracts into the mouth, touching the back of the upper teeth and palate and bending the tip upward at the soft palate;
8) suction of the tongue between the teeth, so that the upper incisors “scrape” the back of the tongue;
9) circular licking of the lips with the tip of the tongue;
10) raising and lowering a wide protruding tongue to the upper and lower lips with the mouth open;
11) alternately bending the tongue with a sting to the nose and chin, to the upper and lower lips, to the upper and lower teeth, to the hard palate and the floor of the oral cavity;
12) touching the upper and lower incisors with the tip of the tongue with the mouth wide open;
13) hold the protruding tongue with a groove or boat;
14) hold the protruding tongue with a cup;
15) biting the lateral edges of the tongue with the teeth;
16) resting the lateral edges of the tongue on the upper lateral incisors, while grinning, raise and lower the tip of the tongue, touching the upper and lower gums;
17) with the same position of the tongue, repeatedly drum the tip of the tongue on the upper alveoli (t-t-t-t-t);
18) make movements one after another: tongue with a sting, cup, up, etc.
The listed exercises should not be given all in a row!
Each small lesson should consist of several elements:
- breathing exercises,
- articulation gymnastics,
- training in pronouncing sounds.
Working on sounds requires a lot of attention and effort.
1. Usually the production of sounds begins with the sound “a”. The tongue is at rest, the mouth is wide open. When making a sound, the tongue is slightly retracted, the lips are pushed forward; When making the sound “u”, the lips are pulled out with tension into a tube, and the tongue is pulled back even more. When making the sound “e,” the tongue rises slightly in the middle part, the mouth is half-open, and the lips are stretched. These sounds are easy to pronounce by imitation; the main task in their production is to eliminate the nasal connotation. Initially, sounds are practiced in abrupt, isolated pronunciation with a gradual increase in the number of repetitions per exhalation, for example:
a o u e
a a o o u u e e
a a a o o o u u e e e
With each pronouncement, control over the direction of the air stream is necessary. To do this, the child holds a mirror or light cotton wool near the wings of the nose. Then the child is trained in repeating vowels with pauses, during which he learns to keep the soft palate in a raised position (he needs to be shown the correct position of the soft palate in front of a mirror). Pauses are gradually increased to 2-3 s. Then you can move on to smooth pronunciation.
2. The production of consonant sounds begins with the sounds “f” and “p”. When pronouncing the sound "f", the tongue lies calmly at the bottom of the mouth. The upper teeth lightly bite the lower lip. A strong oral exhalation breaks this stop and forms a jerky “f” sound. Air leaks are checked using a mirror or cotton wool.
Exercises for setting and consolidating sounds should be carried out in large quantities and in a variety of combinations. A good technique that facilitates the introduction of sounds correctly pronounced in an isolated position into independent speech is singing. During singing, the closing of the soft palate and the back wall of the pharynx occurs reflexively, and it is easier for the child to concentrate on articulating sounds.
Your doubts
From the moment your baby is born, you should absolutely know that his fate is in your own hands almost equally as in ours. By presenting information about the rehabilitation system for a child with a cleft lip and palate, I wanted to convince you of the reality of achieving good treatment results. Your child may have an attractive appearance, normal speech, and beautiful teeth and bite.
I advise parents
When consulting a child with a congenital cleft lip and palate in a particular medical institution, you should receive reasoned answers to a number of questions:
- What types of surgical intervention will your child undergo and at what age?
- What is the reason for the choice of this surgical treatment tactics?
- How many children with this pathology are operated on in this medical institution annually?
- How often are postoperative complications recorded (dehiscence of postoperative sutures, formation of palate defects)?
- What are the cosmetic results of treatment for children, presented in the form of photographs (immediate and distant) and how are deformities of the upper lip and nose eliminated in the future?
- What are the functional results of treatment: how often does typical speech pathology develop - rhinolalia and deformities of the upper jaw/occlusion?
- Is there a comprehensive rehabilitation system in this institution (speech therapist, orthodontist, ENT doctor, pediatrician, neurologist, pediatric anesthesiologist)? How long and how will it be carried out?
Literature
- Ermakova I.I. Speech correction for rhinolalia in children and adolescents. - M., 1984
- Ippolitova A. G. Open rhinolalia. - M., 1983
- Speech disorders in preschool children. Comp. R. A. Belova-David, B. M. Grinshpun. - M., 1969
- Chirkina G.V. Children with articulatory disorders. - M, 1969
- Speech therapy. Textbook for pedagogical institutes in the specialty “Defectology”, ed. Volkova L. S. - M: Education, 1989
- Soboleva E. A. Rhinolalia: general information about rhinolalia; classification of congenital cleft lip and palate; causes, mechanisms, forms of rhinolalia, etc. - M: AST Astrel, 2006
Rhinolalia(Greek rhinos - nose; lalia - speech) - a violation of the timbre of the voice and pronunciation of sounds, caused by anatomical and physiological defects of the speech apparatus and characterized by a peculiar combination of incorrect articulation of sounds and voice disorders. With rhinolalia, the pronunciation of both vowels (due to the nasal timbre of the voice) and consonant sounds is impaired. Types of rhinolalia: open, closed and mixed.
Speech with rhinolalia
Rhinolalia differs from a similar disorder in mechanism - rhinophonia, in which only the timbre of the voice is impaired, and the articulation of sounds does not differ from normal. In rhinolalia, the mechanism of articulation, phonation and voice formation is caused by a violation of the interaction of the oropharyngeal resonators. With normal phonation, the nasopharyngeal and nasal cavities are separated from the pharyngeal and oral cavities when pronouncing speech sounds other than nasal ones. These cavities are separated by the palatopharyngeal closure.
Simultaneously with the movement of the soft palate during phonation, a thickening of the posterior wall of the pharynx (Passavan roller) occurs, which also helps contact the posterior surface of the soft palate with the posterior wall of the pharynx. When pronouncing nasal sounds “mm”, “n-n”, the air stream freely penetrates into the space of the nasal resonator. An unbalanced resonance leads to a change in the acoustic spectrum of the voice and the appearance of nasality or nasalization, and this is the main sign of rhinophony.
If the change in acoustic parameters is accompanied by a spectrum of deviations in the aerodynamic conditions of speech production (insufficient air pressure in the oral cavity, air leakage through the nasal passages), then adaptation to these conditions creates distortions in pronunciation. This is rhinolania.
Open rhinolalia
With open rhinolalia, the timbre of consonants is also disturbed, mainly those in which nasopharyngeal closure is more accurate in normal ratios. The sound of hissing and fricatives “f”, “v”, “x” is disrupted by the addition of an additional hoarse sound that occurs in the nasal cavity. The plosives "p", "b", "d", "t", "k" and "g" sound unclear because the air pressure necessary for accurate pronunciation is not generated in the oral cavity. With open rhinolalia, the air flow in the oral cavity is so weak that it is insufficient to vibrate the tip of the tongue when producing the sound “r”.
Causes of open rhinolalia
The causes of open rhinolalia are divided into 2 groups: organic and functional. Organic causes are divided into congenital and acquired:
- a common cause of congenital open rhinolalia is cleft soft or hard palate;
- acquired open rhinolalia is formed when a hole appears between the oral and nasal cavities or when the soft palate is paralyzed.
Functional open rhinolalia is explained by the lack of retraction of the soft palate during phonation in children with sluggish articulation. Functional open rhinolalia manifests itself in hysteria, sometimes as an independent defect, sometimes as an imitative one.
Examination for open rhinolalia
Examination for open rhinolalia, as a rule, does not reveal organic changes in the hard or soft palate. A sign of functional open rhinolalia is a violation of the pronunciation of only vowel sounds, while with consonant sounds the velopharyngeal closure is sufficient and nasalization is not detected. The prognosis for functional open rhinolalia is favorable. The nasal timbre of the voice disappears after phoniatric exercises, and pronunciation disorders are eliminated using methods that are also used for dyslalia.
Causes of congenital rhinolalia
Congenital facial defects in an infant occur due to exposure to the embryo during intrauterine development. The embryo experiences a delay in the development of those parts of the gill apparatus from which the embryonic tubercles appear, forming the face, nasal and oral cavities. Unfused processes of the upper jaw with the lower create gaps in the upper lip, face, hard and soft palate. The misalignment of one palatine process with the nasal septum forms lateral defects of the palate, which leads to an open connection of one half of the nasal cavity with the oral cavity.
The dangerous period for the occurrence of clefts is 4-8 weeks of pregnancy. Up to 6 weeks, facial clefts appear, 7-8 weeks - the upper lip and palate. The causes of birth defects are hereditary and are often passed down through the male line. Father's signs:
- asymmetry of the eyes, nasolabial folds,
- deviated nasal septum,
- small tongue defect
- stripe in the sky.
Surgical treatment of children with open rhinolalia
Open congenital rhinolalia requires comprehensive medical, pedagogical and orthodontic approaches. In the early stages, orthodontic closure of the hard and soft palate defect with a temporary obturator is required. A soft rubber obturator is needed when feeding a baby. The rigid obturator is made individually and is worn by the child until surgical closure of the defect in the bottom of the nasal cavity and the velum palatine. The obturator is removed 14 days before the planned operation.
Surgical treatment of rhinolalia is carried out in stages. Cheiloplasty, an operation to restore the upper lip, and uranoplasty, an operation to restore the integrity of the bottom of the nasal cavity, are indicated even for newborns. Contraindications for performing these operations at such an early age:
- anemia;
- pneumonia;
- intrauterine hypotrophy;
- birth injuries;
- asphyxia;
- prematurity;
- congenital heart defects;
- spina bifida;
- fistulas in the digestive tract;
- hypoplasia;
- pulmonary aplasia;
- the presence of other severe developmental defects.
Uranoplasty methods: “gentle” uranoplasty is performed on children over one and a half years old, provided there are no contraindications. A proven way to restore the anatomical structure of the nasopharynx is “radical” uranoplasty, which is traumatic and technically complex. For children 3-5 years old, non-through clefts are corrected, and for children 5-6 years old, through clefts (unilateral and bilateral) are corrected. “Radical” uranoplasty is not recommended in early childhood (up to 3 years), since this surgical intervention often provokes slow growth of the lower jaw.
Closed rhinolalia
Closed rhinolalia is formed when the physiological nasal resonance is reduced when pronouncing speech sounds. If there is no nasal resonance for nasal sounds, they sound like oral “b”, “d” or like “mb” (instead of “b”), “nd” (instead of “d”). With closed rhinolalia, the sound of vowel sounds also changes due to the muffling of individual tones in the nasopharyngeal and nasal cavities. In this case, vowel sounds acquire an unnatural, dead tone in speech.
Causes of closed rhinolalia
The cause of closed rhinolalia is organic changes in the nasal space or functional disorders of the velopharyngeal closure. Organic changes are a consequence of painful phenomena as a result of which the nasal passage decreases and nasal breathing becomes difficult (chronic hypertrophy of the nasal mucosa, mainly of the posterior inferior conchae, polyps in the nasal cavity, adenoid growths, occasionally nasopharyngeal polyps, etc.). Functional closed rhinolalia occurs more often in children and occurs when there is sufficient patency of the nasal cavity.
With normal phonation, a seal occurs between the oral and nasal cavities and vocal vibration penetrates only through the oral cavity. If the separation from the oral cavity is incomplete, the vibrating sound penetrates into the nasal cavity. As a result of breaking the barrier between the oral and nasal cavities, the space for vocal resonance increases. At the same time, the timbre of the vowels “i”, “ya”, “u” changes, during the articulation of which the oral cavity is narrowed. The vowels “e” and “o” sound less rhinophonic, and the vowel “a” is less disturbed than others, since when pronouncing “a” the oral cavity is open.
Mixed rhinolalia
Some authors identify mixed rhinolalia - a speech condition characterized by reduced nasal resonance when pronouncing nasal sounds and the presence of a nasal timbre (nasalized voice). The reason is a combination of nasal obstruction and insufficiency of the palato-pharyngeal contact of functional and organic origin.
Typical combinations of a shortened soft palate, submucosal cleft of the soft palate and adenoid growths, which in such cases prevent air from leaking through the nasal passages when pronouncing oral sounds. The state of speech worsens after adenotomy, as velopharyngeal insufficiency occurs and signs of open rhinolalia appear.
Therefore, a speech therapist should carefully examine the structure and function of the soft palate, determine which type of rhinolalia (open or closed) most disrupts the timbre of speech, discuss with the doctor the need to eliminate nasal obstruction and warn parents about the risk of deterioration in the timbre of the voice. After surgery, correction techniques developed for open rhinolalia are used.
Diagnosis of rhinolalia
Diagnosing rhinolalia is not a problem for a doctor, however, difficulties arise when determining the type of rhinolalia. For differential diagnosis, the patient is examined by the following doctors:
- phoniatrist;
- speech pathologist;
- neurologist;
- speech therapist;
- orthodontist;
- otolaryngologist;
- pediatrician.
The examination reveals the etiology of the disease, determines the nature of pathological changes and the severity of symptoms. The following instrumental diagnostic methods are used:
- electromyography;
- rhinoscopy;
- X-ray of the nasopharynx;
- pharyngoscopy.
These techniques visualize the nature of pathological changes and severity in each individual patient. The speech therapist, using a number of progressive techniques, evaluates the following parameters:
- voice disorders;
- voice mobility;
- structure of the articulatory apparatus;
- parameters of physiological and phonation breathing.
To diagnose open rhinolalia, the Gutzmann technique is used, which is based on the fact that the patient pronounces the sounds “a” and “i” alternately, while the doctor opens and closes the nasal passages. In the presence of pathological changes, the vibration of the wings of the nose is clearly felt, and if the nasal passages are pinched, the sounds are muffled. Thus, it is possible to diagnose the open form of rhinolalia.
Correction of rhinolalia
Correction of rhinolalia in children begins with determining the severity of the anatomical defect. The doctor must make a timely decision about surgical intervention and tell the parents about the possible consequences if this is not done. The final decision regarding surgical treatment is made by the child’s parents. After surgical correction of rhinolalia, the child undergoes coursework with a speech therapist. The specialist must teach the child to correctly make movements with the soft palate and tongue when forming sounds and individual words. Modern correction of rhinolalia allows a child to completely get rid of this pathology when a child reaches school age. The baby is practically no different from his peers.
Eliminating rhinolalia with massage and exercises
To eliminate the nasal tone of the voice, both the child, the speech therapist, and the parents will have to work hard. First of all, you will need to activate the soft palate and make it move. This will require a special massage. If the child is small, adults do the massage:
- With a clean, alcohol-treated index finger (pad) of the right hand, in a transverse direction, stroking and rubbing the mucous membrane at the border of the hard and soft palate (in this case, a reflex contraction of the muscles of the pharynx and soft palate occurs);
- the same movements are made when the child pronounces the sound “a”;
- make zigzag movements along the border of the hard and soft palate from left to right and in the opposite direction (several times);
- Using your index finger, perform acupressure and jerk-like massage of the soft palate near the border with the hard palate.
If the child is already big enough, then he can do all these massage techniques himself: the tip of the tongue will cope with this task perfectly. It is important to correctly show how all this is done. Therefore, you will need a mirror and the interested participation of an adult. First, the child does the massage with the tongue with his mouth wide open, and then, when there are no more problems with self-massage, he will be able to perform it with his mouth closed, and it is completely unnoticeable to others. This is very important, because the more often the massage is performed, the sooner the result will appear.
When performing a massage, you must remember that you can cause a gag reflex in a child, so do not massage immediately after eating: there should be at least an hour break between meals and massage. Be extremely careful and avoid rough touches. Do not massage if you have long nails: they can damage the delicate mucous membrane of the palate.
In addition to massage, the soft palate will also need special gymnastics. Here are some exercises:
- the child is given a glass of warm boiled water and asked to drink it in small sips;
- the child gargles with warm boiled water in small portions;
- exaggerated coughing with the mouth wide open: at least 2-3 coughs on one exhalation;
- yawning and imitation of yawning with the mouth wide open;
- pronunciation of vowel sounds: “a”, “u”, “o”, “e”, “i”, “s” is energetic and somewhat exaggerated.
Articulation exercises for rhinolalia
For open and closed rhinolalia, it can be very useful to perform articulation exercises for the tongue, lips and cheeks. They are designed to activate the tip of the tongue:
- Hang your long, narrow tongue down toward your chin and hold it in this position for at least 5 seconds (repeat the exercise several times).
- Slowly stick your long and narrow tongue out of your mouth (do the exercise several times).
- With a long and narrow tongue, sticking out as much as possible from the mouth, make several quick oscillatory movements from side to side (from one corner of the mouth to the other).
- The mouth is wide open, the narrow tongue makes circular movements, like the hand of a clock, touching the lips (first in one direction and then in the other direction).
- The mouth is open, a narrow long tongue is protruding from the mouth, and moves from side to side (from one corner of the mouth to the other) on the count of “one - two”.
- The mouth is open, the long narrow tongue rises to the nose, then falls to the chin, counting “one or two.”
- A narrow long tongue from the inside presses on one or the other cheek.
Forecast of rhinolalia
The prognosis for correction of rhinolalia is favorable, the disorder is eliminated with the help of special exercises and speech therapy. The effectiveness of overcoming rhinolalia depends on the results of the surgeon’s work, as well as the completeness, quality and early start of work with a speech therapist. Systematic and fairly long-term correction allows us to assume positive dynamics during the course of the disease. At the same time, the material intended for correction must be appropriate for the child’s age, be accessible and understandable. The effectiveness of treatment depends on the following factors:
- characteristics of the child’s personality and intellectual integrity;
- the presence of concomitant pathologies;
- degree of compensatory capabilities;
- how timely the correction was started;
- quality of surgical interventions performed.
The speech environment and the willingness of parents to help the child in all available ways are of decisive importance. The results of the work can be assessed by the degree of normalization of speech function and the absence of nasal speaking. Systematic implementation of all doctor’s prescriptions and speech therapy classes allow us to count on good treatment results. Functional rhinolalia has a very favorable medical prognosis.
Prevention of rhinolalia
Prevention of rhinolalia includes preventing the appearance, as well as removing functional disorders and anatomical defects of the patient’s speech apparatus. Prevention consists of avoiding factors that can cause birth defects in a child even in the prenatal period. If such defects of the speech apparatus do occur, then their timely correction is necessary.
Questions and answers on the topic "Rhinolalia"
Question:Hello. My son had uranoplasty when he was 1.5 years old. At 3.5, an adenotomy was performed. He speaks through his nose and has a strong nasal voice. How can I improve the situation? Is it too late to see a speech therapist? We are not diagnosed with rhinolalia, which doctors should we contact to clarify the diagnosis?
Answer: Hello. Start with a speech therapist.
Question:Hello! I am 20 years old, I had a cleft lip and palate. I went to speech therapists, my speech somehow improved, but the nasal sound remained. This is understandable, the sky is short and does not completely block the passage. Is it possible to somehow reduce nasality with the help of speech therapy? Compensate for speech? Can mastering lower diaphragmatic breathing help with this? Or should we think about lengthening the soft palate? Then there will be scars, but even if they are, is it possible to restore a new long palate after surgery or will the scars greatly affect its functioning?
Answer: Hello. You really need speech therapy. There are techniques for reducing nasal sounds using special exercises for the palate and phonopedic techniques.
Question:Hello! My son is one and a half years old; from birth he has a complete cleft lip and soft palate with a split uvula, partial cleft of the hard palate and alveolar process. The lip was stitched up and we are planning to eliminate the palate defect. How to prepare for surgery, maybe classes with a loop therapist? How can I help the baby now? Gymnastics for the development of the speech apparatus?
Answer: Hello. Everything will be needed only after the operation, in 3-5 months. You will need massage, gymnastics and a speech therapist for classes. Now prepare for the operation.
Question:Hello. A 5-year-old child, after pharyngitis, began to speak through his nose and began to snore heavily at night. The nose is breathing, there is no runny nose. We were treated, but there was no result. What could it be?
Answer: Hello. Speaking through the nose, rhinolalia is a symptom of swelling of the nasal mucosa that does not block breathing. Snoring is a symptom of difficulty breathing through the nose, which is hampered by swelling. You need an x-ray of the paranasal sinuses and an examination of the nose and nasopharynx by an otolaryngologist (using a mirror or endoscope). Then the treatment methods will become clear to you and to your doctor.
Question:Hello. A 17-year-old child has open rhinolalia due to congenital cleft lip and palate. They performed surgeries and visited speech therapists, but it was not possible to achieve normal speech. Poor pronunciation of voiceless sounds. When pronouncing hissing and whistling sounds, the air speaks through the nose. The child began to stutter severely: is this related to rhinolalia? How to achieve good speech with open rhinolalia? And how long will it take?
Answer: Hello! The time depends on many reasons. Continue persistently with your speech therapist.
Rhinophony(palatophonia, disphonia, palatina) - nasal phonation, a peculiar violation of the pitch, strength, timbre of the voice and the melodic-intonation side of speech. Unlike rhinolalia, the concept of rhinophony does not include a violation of articulation and sound pronunciation. This is due to the anatomical and physiological causes of the defect. Rhinolalia usually accompanies congenital clefts of the hard and soft palate, defects of the nasal cavity, when the structure and function of the speech apparatus, and, consequently, the mechanism of formation of the sound side of the child’s speech changes. Rhinophonia occurs mainly against the background of acquired defects of the soft palate and nasal cavity, when the child’s sound pronunciation has already been formed. From an anatomical and physiological point of view, the occurrence of rhinophony is explained by a number of reasons that disrupt the interaction and interdependence of articulatory, laryngeal and respiratory mechanisms, as well as the normal relationship between the nasal and oropharyngeal cavities, which underlies denasalized phonation. With rhinophonia, the relationship between the nasal and oropharyngeal resonators in the process of holoformation is disrupted, as well as the functional connection between the soft palate and the larynx, between the pharynx and larynx, between the soft palate and the respiratory system (especially the diaphragm). The slightest change in the position of the soft palate causes asynchrony and asymmetry in functions of the vocal folds, as well as lethargy, lack of coordination in the work of the respiratory muscles. With paresis, paralysis, cicatricial changes in the soft palate, its shortening and low mobility, the formation of a closing pharyngeal ring (or velopharyngeal seal) is difficult. Respiratory impairment manifests itself in a short shallow inhalation, insignificant volume of inhaled air and large loss of exhaled air through the nasal passages.
Thus, the muscles of the closing pharyngeal ring, the larynx and vocal folds, and the respiratory apparatus constitute a single motor system that synchronously participates in the process of voice formation. In open and closed rhinophony, for various reasons, the unity of the activity of the voice-forming mechanism is destroyed
Thus, open organic rhinophony occurs with congenital shortening, paresis, and paralysis of the soft palate, myasthenia gravis, perforations, fistulas, scars of the hard and soft palate.
The appearance of open rhinophony is also facilitated by a narrow oral opening (Kelly, 1434, Williamson, 1944), a retracted tongue (Hixon, 1949), and an excessively long tongue (Riper Srvm, 1965). 1 Open functional rhinophony appears in weakened, asthenic children with sluggish articulation on the tongue. background of hysterical syndrome, with hearing loss.
Closed rhinophonia is formed with reduced nasal resonance. Its causes are various painful processes in the pharynx: adenoids, polyps, fibroids, deviated nasal septum, swelling of the nasal mucosa, etc.
Rhinophony is characterized by its acoustic characteristics. changes in the pitch, strength and timbre of the voice Nasalization deprives the timbre of pleasant, beautiful modulation, pitch changes, sonority and flight of the voice. With open rhinophony (hypernasalization), weakness and exhaustion of the voice are noted, sometimes its pinched, compressed monotonous sound is sometimes hoarse, hoarse, muffled and falsetto. A dull, “dead” sound of the voice impoverishes the natural speech intonations and melody of speech. Emotional, volitional and logical intonations turn out to be almost inaccessible to these patients. With closed rhinophony (hyponasalization), the timbre of the gopos changes due to the inaccurate sound of vowel sounds - they acquire a denasalized, muffled “dead” dull monotonous unnatural shade due to the muffling of individual tones in the nasopharyngeal and nasal cavities.
Thus, with open and closed rhinophony, a violation of the timbre of the voice is observed - it acquires a shade of hyper or hyponasalization, which is explained by a change in the anatomical and physiological conditions of phonation. Nasalized phonation reduces the expressiveness and beauty of speech. Violation of the melodic-intonation side of speech reduces the child’s communicative capabilities, creating speech and psychological difficulties for him to communicate in a group. Therefore, early speech therapy work creates all the conditions for a child’s full verbal communication and learning.
Speech therapy work by eliminating rhinophony, it is intended to restore the integral functioning of the speech apparatus in all its links. The effectiveness of speech therapy sessions depends on a number of psychophysiological factors.
1) length, mobility of the soft palate and function of the Uvula,
2) mobility of the posterior pharyngeal wall
3) mobility of the tongue, the possibility of its relaxation and tension, as well as its position in the oral cavity
"Quoted from the book. Vinarskaya E. N, P u .... Dysarthria and its topical and diagnostic significance in the clinic of focal brain lesions. Tashkent, 1973, p. 26
4) the volume of the oral resonator,
5) participation of lips, cheeks and jaws in the process of articulation of speech sounds,
6) structure and function of the nasal resonator, 7) mobility of the vocal folds,
8) activity of the respiratory apparatus The age of the child and the function of his perceiving apparatus, which gets used to the nasalized sound of the voice, are also of great importance. Therefore, a necessary condition for the success of speech therapy work is an understanding of the anatomical and physiological mechanisms of speech and voice formation under normal and pathological conditions, as well as knowledge of the basics of developmental and educational psychology.
The initial link in speech therapy work is clinical speech therapy examination children suffering from rhinophonia.
An otorhinolaryngologist (or phoniatrist) summarizes the patient’s complaints and anamnestic data about the early general development of the child, examines the nasopharynx, oropharynx, and laryngopharynx. In this case, attention is paid to the structure of the resonators and their functioning.
I Examination of the nose and nasopharynx (shape and volume of the nasal cavity, presence of obstacles to normal voice production - adenoids, polyps, fibroids, deviated nasal septum, choanal fusion, swelling of the nasal mucosa, etc.). II Examination of the oral cavity and oropharynx (presence and condition of teeth, bite, shape of the hard palate, length and mobility of the soft palate and Uvula, condition of the tonsils, shape and mobility of the tongue)
III Examination of the larynx(condition of the mucous membrane, mobility of the elements of the larynx, vocal folds and vescibular folds, condition of the interarytenoid space, nature of the closure of the vocal folds, shape of the glottis) The presence of “nodules” of fibromas, pallipules or other neoplasms is noted in singers.
IV Ear examination(auditory canal, eardrum, hearing test)
If necessary, an additional special examination is prescribed: stroboscopy, radiography and tomography of the larynx, spirometry and pneumography, as well as examination of patients by a therapist and a neurologist
A systemic speech therapy examination reveals the developmental features of the patient’s speech and voice function. The level of speech development is determined by describing the child’s complaints when compiling a story from a picture, from a series of retelling pictures, etc. At the same time, the sound is recorded vote its height, strength, duration, timbre, modulation, quality of the vocal voice. Speech therapy examination reveals not only the structure and function of the resonator, generator and respiratory
systems, but also their interconnected functioning, which, according to physiology, has a regulatory effect on the formation of voice timbre.
The “energy” system (respiratory) provides energy for vibration of the vocal folds, increasing the strength of the voice.
The “generator” system (voice-forming) produces the sound of the voice, the fundamental tone and many overtones. The fundamental tone and overtones are amplified and modulated thanks to a system of resonators of the pharynx, oral cavity, nasal cavity and paranasal sinuses. The resonator system forms vowel and consonant sounds and differentiates them according to noise characteristics. Therefore, the study of a patient suffering from rhinophony begins with an examination of his resonator system. I. Articulatory apparatus, its structure and function.
1) Structure: dental-maxillary system, lips, tongue, hard
and soft palate (length, facial scars, fistulas, submucosal fissure), Uvula.
2) Mobility of lips, cheeks, jaws, tongue, soft palate Uvula. Accuracy, clarity, smoothness, proportionality, strength, synchronicity and switchability of articulatory movements are noted.
3) Mobility of the facial muscles, participation of facial expressions in the process of speech and voice formation.
4) Clarity of diction when pronouncing vowels, consonants (direct, reverse, closed, with consonants) words, proverbs, sayings, tongue twisters.
II. Respiratory apparatus, its function. :
1) Breathing at rest - the nature and depth of inhalation and exhalation are noted.
2) Breathing during speech - the nature, depth and type of breathing, the possibility of differentiating nasal and oral breathing, the strength, duration of oral exhalation, the presence of air leakage through the nasal passages are noted.
The functioning of the vocal apparatus is revealed indirectly when pronouncing vowels, consonants, syllables, words, reading texts when singing scales and songs. At the same time, the height, strength of the timbre of the voice, and the melodic and intonation side of speech are noted.
1) Sound strength - the ability to change the strength of the voice is tested when pronouncing vowels, syllables, words, reading texts (from whispering to loud pronunciation with gradual strengthening and weakening of the voice, from forte to piano).
4) The melodic-tonation side of speech is characterized by the degree of use of expressive means of speech: stress, pauses, timbre and modulation of the voice, changes in tempo, rhythm and volume of speech. It is noted how, with initiative, stimulated and automatic speech, the child conveys the main intonemes: question, exclamation, statement, surprise, delight, fear, anger, pain, contempt, indignation, admiration, etc.
A voice of medium volume, medium register, ringing, strong, “flying,” modulated, melodic, natural, clear, lively, conveying all the shades of thoughts and feelings, all the intonation richness of the language is taken as the standard sound.
A disturbed voice is a voice that is dull, hoarse, hoarse, rough, harsh, strangled, pinched, weak, quiet, drying up, nasalized, monotonous, “dull,” “metallic,” falsetto, diplophonic, screaming and barking. During a speech therapy examination, the patient's voice is recorded on tape.
A speech therapy examination also reveals the patient’s perception of his own and others’ speech. According to psycholinguistics, the perception of intonation is determined by its physical properties, the structure of perceived qualities, the linguistic meanings of intonation, the plan of thought and the attitude of the auditor. Due to long-term voice impairment in a patient suffering from rhinophonia, a restructuring of speech hearing occurs, adaptation to nasal phonation occurs, and pathological afferent kinesthetic impulses from the speech organs are formed. Therefore, such a patient does not control his hearing and does not differentiate between paralyzed and normal sounds.
During the examination, some psychological and pedagogical features the child - his intellectual development, character, behavior, mood, attitude towards the defect, which is of great importance for the effectiveness of speech therapy work. One group of patients is hopeless and indifferent to their defect, has become accustomed to it, and has a reduced volitional impulse to overcome it. Another group suffers from a defect, is embarrassed about their voice, sometimes refuses to communicate with others (especially in adolescence), and strives to eliminate nasalization.
Having systematized and summarized the data from the clinical-logopelic examination, the speech therapist proceeds to corrective work to eliminate rhinophony, which poses a significant difficulty.
The method of speech therapy work we propose to eliminate the nasal tone of the voice is based on the experience of the German and French speech therapy school in correcting rhinolalia. Thus, T. Gutzman used articulation, breathing exercises, general body gymnastics, electric massage, vibration massage and speech exercises. Being a representative of the power direction in speech therapy, G. Gutzman proposed jerky, sharp, short pronunciation of sounds with great tension in the muscles of the neck and shoulder girdle, with strong blows with his fist to the table or knees. When producing consonants, he recommended clamping the wings of the nose to create strong internal pressure, which should passively lift the flaccid velum.
When working on the voice, G. Gutzman (and then M.E. Khvattsev) suggested using a falsetto voice, transferring it to a chest sound after 2-3 months. All exercises were of a strength nature and required a lot of effort from the student.
V. Vaud and S. Borel-Mesoni (France), representatives of the gentle direction in speech therapy, laid the foundations of the orthophonic method of voice production. They proposed training in correct breathing and voice “in a mask”, as in learning to sing, and assigned a special role to vocal exercises. At the same time, natural, relaxed breathing and voice exercises were recommended.
Subsequently, Soviet scientists and speech therapists (E. F. Pay, Z. G. Nelyubova, M. E. Khvattsev, A. G. Ippolitova, etc.) modified and supplemented the German and French methods in relation to the phonetic system of the Russian language. Particularly interesting and instructive are the methodological techniques for correcting defective sound pronunciation in rhinolalia. But in the literature, the methodology of speech therapy work to eliminate the nasal tone of the voice, to develop its pitch, strength and timbre, as well as the melodic-intonation side of speech, is almost not disclosed.
Currently, the most appropriate and effective method of eliminating rhinophony is the complex orthophonic method, which assumes that the examination and treatment of these patients requires the participation of an otolaryngologist, phoniatrist, physiotherapist, teacher and speech therapist.
The main goal of orthonic treatment- creation or restoration of a functional relationship between breathing, articulation and voice formation. In this regard, the following tasks of speech therapy work are highlighted:
1) differentiation of nasal and oral breathing;
2) obtaining a long and strong oral exhalation;
3) activation of the muscles of the soft palate and the posterior wall of the pharynx;
4) evoking a loud, ringing, strong, “flying”, modulated voice without a nasal tint;
5) development of the melodic and intonation side of speech; . 6) development of auditory control. Speech therapy work is carried out under the control of auditory and motor. tactile vibration and muscle sensations, playing the role of those proprioceptive (afferent) signals that are the controlling link in the process of speech and voice formation.
There are two stages of speech therapy work to eliminate the nasal tone of the voice:
The first is the preparatory stage, which includes:
1) psychotherapy;
2) articulation gymnastics;
3) activation of the muscles of the soft palate and the posterior wall of the pharynx, -
4) breathing exercises.
The second is the main stage, which includes:
3) development of the duration and strength of the sound of the voice;
5) development of the melodic-intonation side of speech. In the process of speech therapy sessions, it is difficult to make a sharp distinction between these stages. The work is carried out sequentially and in parallel, individually and frontally. But it should be noted that voice development is impossible without first establishing speech breathing, differentiating nasal and oral breathing, and activating the muscles of the soft palate and pharynx. At each subsequent stage, speech therapy techniques become more complex and specific breathing and voice exercises are added to normalize the process of voice formation. Preparatory stage The goal is to prepare the child’s articulatory and respiratory apparatus for subsequent intensive voice exercises, as well as to activate the child’s personality to overcome the defect, stimulate his motivational sphere, the need for activity, and adjust speech perception (speech hearing) to the correct sound of the voice.
The initial element of speech therapy work is rational psychotherapy, the goal of which is the conscious, active, voluntary inclusion of the child in the process of eliminating ripofonin psychotherapy involves an individual approach to the patient, taking into account his age, personality characteristics, nature and duration of the voice disorder. During the conversations, the patient’s complaints are identified, an idea of his range of interests and attitude towards the defect is formed, and personal and work contact is established. The speech therapist instills in the patient confidence in the success of the sessions and demonstrates tape recordings of the voices of other patients before and after speech therapy sessions. Simultaneously with psychotherapy, articulatory gymnastics, activation of the muscles of the soft palate and the posterior wall of the palate are carried out, and vocal exercises are introduced 1
The purpose of articulation gymnastics is to develop clarity, dexterity, and correct movements of all parts of the articulatory apparatus. It is necessary, on the one hand, to reduce stiffness and tension of the articulatory muscles, on the other hand, to increase their tone and strength. Articulatory gymnastics activates the oropharyngeal muscles, or, conversely, their relaxation reduces the excessive participation of the back and root of the tongue, larynx during phonation (relieves laryngeal hyperfunction) As is known, with rhinophonia there is excessive tension in the facial muscles - the patient tries to reduce the nasal tone of the voice, while wrinkles the nose, forehead, frowns, and shifts the eyebrows. To relieve tension from the facial muscles, a hygienic massage is used, which consists of lightly stroking the forehead, nose, cheeks, and lips with the tips of the fingers.
Articulation gymnastics, generally accepted in speech therapy, are used, differentiated for various parts of the articulatory apparatus. Gymnastics are performed in front of the mirror rhythmically, smoothly and clearly.
1. Movement of the jaws. A special role is given to exercises for the lower jaw, since the degree of mouth opening depends on it, which determines the formants of vowel sounds. On the other hand, the lifting of the soft palate depends on the movements of the lower jaw; when pronouncing ah, uh the soft palate is raised as much as possible when pronouncing o, y, i- omitted.
Exercises for the jaws: opening and closing the mouth, imitation of chewing, lateral movements of the lower jaw, silent vowel pronunciation A, uh, and, oh, y. In this case, attention is paid to the quiet position of the root of the tongue - the tip of the tongue at the lower incisors (dorsal position).
2. Movement of the lips: stretching forward with a tube, folding in a circle, stretching in a smile, strengthening the lips when silently pronouncing a consonant p-p-p and vowels u-o-i.
3. Tongue movement: sticking out the tongue, turning left and right, licking lips, strengthening the tip of the tongue - biting, “clicking” the tip of the tongue, sucking on the lower and upper incisors, pushing through clenched teeth, pronouncing t-t-t, d-d-d, r-r-r If there is excessive tension on the back and root of the tongue, tapping the middle part of the tongue with a spatula, sticking out a wide spread tongue, massaging the tip of the tongue, and vocal exercises are used.
4. Gymnastics for the neck muscles to relax the pharyngeal and laryngeal muscles, lowering the head down, throwing it back,
1 For the methodology for conducting vocal exercises, see and on page 101 Singing is conditionally classified as the main section of speech therapy work
turns the head left and right, later these movements are combined with the pronunciation of sounds a-e-i o-u
1) Vibration massage of the larynx to activate the vocal folds - vigorous, rhythmic movements of the fingers are made along the front surface of the neck in the vertical and horizontal direction with light pressure on the area of the thyroid cartilage;
2) Stroking massage of the larynx
3) Imitation of a pigeon cooing, moaning, mooing, barking, crying.
4) Pronouncing vowel sounds a-e-i-o-u
5) Singing vowel sounds 6. Activation of the soft palate.
1) Massage of the soft palate - stroking, kneading movements with a finger are made along the midline of the hard and soft palate from the upper incisors to the Uvula to obtain a pharyngeal reflex.
2) Active gymnasgy of the soft palate: yawning, swallowing water, saliva, coughing, gargling, imitation chewing, pronouncing vowels a, e on a hard attack. At the same time, the ability to simultaneously lift the soft palate, then hold it for a long time and count in a submerged position, is trained. This stimulates the pharyngeal and laryngeal muscles. Sample exercises.
7. Exercises for the development of clear, coordinated work of all parts of the articulatory apparatus (pa6ota over diction), which involves simultaneous training of breathing and voice.
1) Pronouncing vowels in a whisper and loudly
"A dot over a letter means a short, solid pronunciation
2) Pronouncing syllables and words while exhaling. Consonants are trained in a certain sequence - according to the degree of their articulatory complexity, the duration of exhalation and the participation of the voice:
in, uh, g. f, s, w, l, r..b. d. G. P, g, k". In this case, syllabic exercises are pronounced in a loud voice (and not in a whisper). This is explained by a number of anatomical and physiological conditions for the formation of voiceless and voiced consonants. Thus, voiced consonants require::
b) less force of articulation (for deaf people, greater force of articulation);
c) lowering of the larynx (for deaf people, raising of the larynx); " d) shorter duration of the stop (for deaf people, longer duration of the stop);
e) less explosive force (with deafness, greater explosion force). Therefore, when pronouncing voiced consonants, tension is relieved from the articulatory and respiratory apparatus, larynx, and pharynx due to less muscle effort.
Whispering is advisable if laryngeal hyperfunction is observed, i.e. a compressed, tense, tight, hoarse sound of the voice. In this case, “phonation is turned off to eliminate the pathological participation of the larynx and articulation” 2. After the laryngeal tone disappears, loud sound training begins 3.
Simultaneously with psychotherapy, articulation gymnastics, and activation of the soft palate, breathing exercises are performed. The latter will occupy a special place in the system of correctional work, since the effectiveness of speech therapy classes depends mainly on two factors: the activity of the soft palate and the duration of oral exhalation. The goal of breathing exercises is to differentiate nasal and oral breathing, obtaining a long oral exhalation under the control of the movements of the diaphragm and abdominal muscles. The diaphragm regulates the level of subglottic air pressure, increasing or decreasing the force of closure, frequency, and amplitude of vibrations of the vocal folds.
When eliminating rhinophony, static and dynamic breathing exercises are used, but at the initial stage of speech therapy classes, static exercises are especially important, which fix the child’s attention on a long oral exhalation.
Static exercises include blowing on cotton wool, blowing on water, blowing soap bubbles, rubber toys, balls, blowing out candles, playing the pipe, flute, harmonica (which develops the labial muscles, trains extended exhalation, forms kinesthetic sensations from the muscles of articulation, breathing and vocal device, thereby adjusting the child’s auditory perception to the correct sound of the voice). When performing static breathing exercises, nasal and oral inhalation and exhalation are differentiated (inhale through the nose - exhale through the nose, inhale through the nose - exhale through the mouth, inhale through the mouth - exhale through the mouth). In this case, the child should not strain his shoulders,
neck and fill your chest with air.
Playful breathing exercises are very useful for working with children:
1) “Flower shop” - deep slow training
inhale through the nose.
2) Candle - training for an even, slow exhalation into a candle flame.
3) “Stubborn suppository” - training for intense strong exhalation.
4) “put out the candle” - training in intense, interrupted exhalation with pronouncing ugh! ugh!
5) Training for prolonged exhalation while pronouncing sound combinations for a long time "pshshipi"...
6) “Mosquito” - training for a long exhalation with a long pronunciation zzzz... 7) “...” - long exhalation training with long pronunciation SSSSS... .
Then a loud and prolonged pronunciation of vowels and their combinations, voiced and voiceless fricatives and plosive consonants, and syllables is activated:
When pronouncing sound combinations and syllables, the child’s attention is constantly fixed on a long oral exhalation, a raised soft palate, air leakage through the nose is controlled, and auditory control is activated. This combination of articulation and breathing exercises develops speech breathing skills.
Following static breathing exercises, dynamic exercises are used. The latter physically strengthens the child’s body, improves the function of his diaphragm and abdominal muscles, develops phonation breathing, prepares him for intense voice exercises, and positively influences the child’s mood and emotions, causing him to feel joy and cheerfulness. Dynamic exercises include walking, slow running, and movements of the arms, legs, and torso. They are more excisable, natural and strong compared to static ones. Dynamic breathing exercises are based on a combination of torso movements and limbs with the utterance of sounds, sound combinations as you exhale.
Thus, articulation and breathing exercises prepare the child for voice exercises to eliminate rhiophony.
Main stage speech therapy classes begin with voice pitch development-one of the most important means of his expressiveness. Changing the pitch improves the range, modulation, and flexibility of the voice, enhancing the expressiveness of speech and the richness of its intonation coloring. When rhinophony is eliminated, the development of voice pitch begins with vocal exercises, under which the most favorable anatomical and physiological conditions are created for the functioning of the vocal apparatus. When singing, the vocal folds do not shorten or lengthen, do not thicken or thin, and the pharyngeal resonator does not change its shape; as the tone increases, the epiglottis and palatal curtain rise, the oral resonator increases in volume, but almost does not change in shape, the mouth is wide open, the tongue lies calmly at the bottom of the oral cavity, pressing against the lower incisors, while the back and root of the tongue are relaxed. The mouth becomes a powerful sound emitter.
Vocal exercises are carried out by imitation with musical accompaniment. They start with singing vocalises (melody without words). Vocalises are sung with one vowel sound, i.e. vocalized. Vowel sounds are vocalized in the following sequence ah, uh, oh, y, And, this takes into account the degree of elevation of the soft palate, tension of the back and root of the tongue, and the degree of mouth opening Ah, uh- the loudest sounds due to the lowest impedance") in the oropharyngeal cavity.
Initially, the vowels are sung in legato that is, coherently, smoothly, the sound “flows” easily and freely. The child sees a wide-open mouth, a raised soft palate, feels the movements of the diaphragm, abdominals, vocal folds, and hears his own clear, sonorous voice. unnatural voice. Then the scale is sung (with a gradual increase in the number of tones), which develops evenness, melodiousness, flexibility, and modulation of the voice. When singing scales, the sound of the voice should not tremble or force itself. Singing song melodies
on vowel sounds, which trains smooth and slow singing with raising and lowering the voice. Having practiced the techniques of coherent, smooth, slow (canted) singing, you can move on to exercises at a faster tempo (vowels, syllables, scales are sung). These exercises also train the strength of the voice. Singing songs at the initial stage of learning to sing, short musical phrases and a simple rhythm predominate in songs. , not fast paced, simple verbal text. Including text creates additional difficulties for the child and complicates control over the sound of the voice. Therefore, singing songs is introduced only when the clear speech sound of consonant sounds and their combinations has been worked out. The song should be emotionally charged, joyful, cheerful, and correspond to the child’s age and his vocal capabilities.
Vocal exercises are carried out at all stages of a child’s education, from the very first lessons. They are, on the one hand, a kind of gymnastics for the vocal apparatus, and on the other hand, they enrich the timbre of the child’s voice, contribute to the development of his speaking voice, and adjust auditory perception to the correct sound of the voice.
Speech skills are also trained simultaneously with vocal exercises. utterance vowels, their combinations, syllables. Games that develop the pitch of the voice are very useful for children. Games liberate the child’s vocal apparatus, cause a joyful rise in his mood, activate emotional reactions, increase the overall tone of the body, so when playing games the voice sounds cheerful, cheerful, confident, free and easy. Games are held both in individual and group lessons
Passive gymnastics has this name because the movements of the organs of articulation are performed by a speech therapist.
drip liquid from a pipette onto the root of the tongue, while the child’s head is tilted back slightly. This exercise stimulates the elevation of the soft palate. When performing it, you can use juice instead of water;
lightly press on the root of the tongue with a spatula; This exercise requires some caution, as sudden movements can cause a gag reflex.
Active gymnastics of the soft palate.
Passive gymnastics is combined with special exercises to activate the velum palatine:
gargle with your head thrown back in small sips. This exercise produces the greatest effect if, when performing it, instead of water, you use a heavy liquid such as kefir, thin yogurt or jelly;
cough randomly; in this case, coughing is not done at the level of the larynx, as is done when there is discomfort in the throat, but at the level of the soft palate. These actions cause a reflex contraction of the muscles of the posterior pharyngeal wall and contribute to the formation of complete velopharyngeal closure. First, coughing is done with the tongue sticking out. The air flow is directed into the oral cavity. Thus, while completing the task, in addition to activating the soft palate, children train in producing a directed air stream;
imitate yawning. Exercise improves blood circulation in the brain and increases the outflow of venous blood;
pronounce vowels A-E-O in an exaggerated manner on a hard attack. At the same time, pressure in the oral cavity increases and nasal emissions decrease;
slowly, silently pronounce the vowels A-E-O, while trying to maintain clear articulation;
sing vowels with gradual strengthening and weakening of the voice.
Let us give an example of an exercise for activating the muscles of the velopharyngeal ring in the game situation “Masha (Teddy Bear, elephant, etc.) wants to sleep,” which can be used in work with preschool children. To do this, you need several dolls or soft toys depicting various animals. The speech therapist, together with the child, chooses which toy they will put to bed.
L.: When evening comes, it becomes dark outside and all the toys must go to bed. So Mishka wants to sleep (shows how he yawns), so the dog also wants to sleep and yawns (shows). Now show them how they yawn.
L.: What about the Mashenka doll? She is a little capricious and wants to be sung a song before bed. Let's sing her a lullaby:
Bye-bye, bye-bye, go to sleep quickly! A-A-A.
The child listens carefully to the song and then chants the vowel sounds.
L.: Look, Mashenka is already closing her eyes and yawning. Show me how she does it. Well, now she's definitely asleep.
Such exercises, in addition to activating the muscles of the velopharyngeal ring, contribute to the formation in the child of a long, directed oral exhalation during phonation.
Elimination of nasal tone of voice.
To achieve these goals, preparatory work is carried out to strengthen the velopharyngeal closure, activate the diaphragmatic muscles and form a targeted oral exhalation.
Phonopedic exercises help activate the muscles of the entire laryngeal-pharyngeal apparatus. Learning proper voice skills begins with singing vowel sounds. At first, children learn to sing the vowels [a] and [o], after 2-3 lessons the sound [e] is added. The last sounds to be included are [i] and [u].
The exercises begin with the isolated pronunciation of vowels, then move on to singing their combinations. The number of vowels in combinations gradually increases to three. Here is an example of such exercises:
A JSC AE AI AU AOE AEO AOI AEU
About OA OE OI OU UAE OEA OAI OEU
E EA EO EI EU EAO EOA EAI EOU
IA IO IE IU IAO IOA IEA IAE
U UA UO UE UI UAO UOA UEO UOE
Training begins with showing and explaining articulation. Then the child tries to repeat the necessary actions in response to the speech therapist. First, the exercises are performed in a whisper, then loud pronunciation is included. The child's attention is drawn to the wide opening of the mouth, the position of the tongue: the tip is moved towards the lower incisors, the root of the tongue is lowered down. Sound combinations should be pronounced long and smoothly in one exhalation. Air leakage through the nose is controlled by using a mirror or vial held to the child's nose.
During classes, you can offer children game situations. For example, rocking a doll, a child will hum: [a]-[a]-[a], showing how big he is: [o]-[o]-[o], how the steamboat hums: [u]-[u]- [y], on a walk in the forest he screams [ay!], etc.
The use of static and dynamic breathing exercises helps to achieve a good effect.
standing, raise your arms up through your sides, stretch, inhale, lowering your arms, sing [a] as you exhale;
standing, arms down along the body, raise your arms up, take a deep breath, tilt your body forward, lower your arms while singing the vowel [o];
standing, hands on your belt, inhale, as you exhale sing [e], stretching your hands clasped in your palms forward, imitating the movements of a swimmer.
At the next stage, children move on to exercises with pronouncing sound combinations with consonants in an intervocalic position: vowel - consonant - vowel. In the exercises, only correctly articulated consonants are used: nasal sounds [m], [n]. Sound combinations are pronounced together, smoothly, first monotonously, quietly, then with a change in the pitch of the voice.
gradual lengthening of the pronunciation of sounds on one exhalation at an average volume of the voice;
counting to ten with a gradual strengthening and subsequent weakening of the voice;
similar pronunciation of the alphabetical series;
reading poems with a gradual change in voice strength.
To develop the pitch of the voice, exercises are used aimed at gradually expanding the range (volume) of the voice, developing its flexibility and modulations, for example, raising and lowering the voice when pronouncing vowels, their combinations of two and three sounds. Subsequently, they use the recitation of poems with a change in the range of the voice.
Phonopedic exercises are carried out not only by a speech therapist, but also in classes with a music worker. Singing is performed to the accompaniment of a piano.
In children who do not have anatomical disorders or functional disorders of the speech apparatus, it is possible to completely normalize the ratio of nasal and oral resonance and eliminate the nasal tone of the voice. In children with a defect in the anterior part of the hard palate, hypernasalization is significantly reduced, practically remaining minimal. Restoring the integrity of the anatomical structures of the hard palate will contribute to the final elimination of nasal tint.
The greatest difficulties in eliminating the pathological skill of voice formation are encountered in the process of correctional work with children in whom nasopharyngoscopy examination reveals the presence of velopharyngeal insufficiency. Eliminating hypernasalization using a conservative approach in these cases is impossible. Exercises to activate the muscles of the velopharyngeal ring allow one to achieve only visual mobility of the velum palatine. Such children undergo surgery to correct velopharyngeal insufficiency. The final results of the operation can be judged after one year. All this time, children continue to attend speech therapy classes, excluding the period of postoperative rehabilitation for a period of 21 days.
School-age children with this pathology experience general underdevelopment of speech, impoverished vocabulary and grammatical structure. These phenomena have various causes - the social and speech contact of such children is limited, which is caused by a pronounced impairment of spoken speech, a late onset of sound speech, and the addition of dysarthria or alalia to the main disorder. Such children have a limited and imprecise vocabulary, speech errors, and a low level of mastery of syntax, vocabulary and literary language. All this is a consequence of a lack of speech practice. Speech becomes stereotypical, words are replaced with similar meanings.
Written speech is characterized by errors in the use of prepositions, conjunctions and particles, and in the endings of cases. This can be called written agrammatism. Also characteristic are incorrect divisions of sentences and combinations of prepositions with other parts of speech, mainly with nouns.
When reading, there is also the influence of unformed oral speech. Mixing of parts of words is noticeable, word forms are not always differentiated, and the reading pace is slow. Understanding of the material read is impaired to varying degrees: from misunderstanding of individual words to impaired understanding of the semantic content of parts of the text, figurative meaning.
CORRECTIONAL WORK METHOD
Correction when teaching those children with rhinolalia who have only phonetic disorders is carried out as follows.
1. Activation of the articulatory apparatus. In this case, various techniques are used, depending on the state of the peripheral articulatory apparatus and congenital pathology.
2. Formation of articulatory sounds.
3. Differentiation of sounds to prevent further disruption of sound analysis.
4. Reducing the nasal sound of the voice.
5. Elimination of violations of the prosodic side of speech.
6. Bringing acquired skills to automatism with free speech.
All of the above is taken into account when working with children with impaired phonetic-phonemic development, and systematic classes are conducted to normalize phonemic perception, create morphological generalizations and eliminate dysgraphia.
Speech therapy assistance to children with general speech underdevelopment consists of developing in patients full phonetics, phonemic concepts, the formation of morphological and syntactic associations and generalizations, and coherent spoken speech.
These techniques are used in specialized schools for children with severe speech defects.
Domestic speech therapists have developed a number of techniques to eliminate rhinolalia. These are the methods of A. G. Ippolitova, Z. A. Repin, I. I. Ermakov, G. V. Chirkin, T. V. Volosovets.
System of A. G. Ippolitova. Its use is highly effective when working with children who do not have deviations in phonemic development. When using this system, it was proposed for the first time to conduct classes before surgical correction of the defect. The main thing in this technique is a set of breathing and speech exercises, a sequence of practicing sounds that are interconnected articulatory. The stages in practicing sounds are determined by the degree of readiness of the articulatory base of the language. If there are full-fledged sounds of the same group, then this is considered an arbitrary basis for working on the following. So-called “reference” sounds are used. The articulatory base is prepared using specially developed articulatory gymnastics. It accompanies the development of speech breathing. The uniqueness of this method lies in the fact that when producing a sound, the child’s initial concentration is concentrated only on the articulomes. The speech therapy system of A. G. Ippolitova consists of several main sections.
1. Formation of speech breathing when differentiating inhalation and exhalation.
2. Formation of a long oral exhalation when the articulation produces vowel sounds (without including the voice) and fricative voiceless consonants.
3. Differentiation of short and long nasal exhalation in the formation of sonorant sounds and affricates.
4. Formation of soft sounds.
According to the method of L.I. Vansovskaya, the elimination of nasality of sound begins not with the vowel [a], as usual, but with the front vowels [i], [e], since with the help of these sounds the exhaled air flow can be focused in the anterior part of the oral cavity and direct the movement of the tongue towards the lower incisors. When the tongue comes into contact with the lower incisors, kinesthetic clarity is enhanced, and the movement of the pharyngeal walls and soft palate is activated when pronouncing the sound [i]. The child must pronounce the required sounds quietly, while the jaw protrudes slightly forward, a half-smile and strengthening of the muscles of the pharynx and soft palate are necessary. After the vowels lose their nasal sound, work is carried out on the sonorant consonants [p], [l], and then on the fricative and stop consonants.
X-ray examination is of great importance when choosing and improving correctional techniques. With its help, you can predict the success of speech therapy measures and restoration of palate functions. Using radiographs, the dependence of the effect of speech therapy assistance on the mobility of the soft palate and posterior pharyngeal wall was revealed; on the distance between the posterior parts of the pharynx and the soft palate; from the width of the middle part of the pharyngeal cavity.
For adult patients, you can use the technique of S. L. Taptapova. In this case, it is recommended to pronounce vowel sounds in silent mode (pronouncing to oneself). This eliminates excessive facial expressions and helps the beginning of pronunciation without a nasal tone. This technique also uses vocal exercises.
Methodology of I. I. Ermakova. It consists of consistent correction of the pronunciation of sounds and voices. Ermakova identified age-related features of functional disorders of voice formation in children with congenital clefts. Orthophonic exercises have been improved for them. Much attention is paid to the postoperative stage. At the same time, techniques have been developed to increase the mobility of the soft palate, which can be shortened after surgical treatment.
To eliminate sound speech disorders, a thorough speech therapy examination of the child is required.
During the examination, the following defects and deformations are revealed: velopharyngeal insufficiency, its severity; size (length) of the soft palate, scars on the hard and soft palate; the nature of contact with the posterior wall of the pharynx (passive, active, functional); anomalies of teeth, jaws, alveolar processes; specifics of the activity of the articulatory apparatus; the presence of additional compensatory facial expressions.
The effectiveness of speech therapy assistance is closely related to the anatomical and functional characteristics of the speech apparatus. In addition, a correct assessment of the child’s psychophysical and psychoemotional status and his personal characteristics is very important.
The speech correction system for children with rhinolalia contains several sections:
1) work on the mobility of the soft palate;
2) elimination of nasality;
3) production of sounds and work on correct phonemic perception.
The content of the first section varies depending on whether surgical correction was performed or not. If surgical treatment was carried out, then a number of therapeutic measures are necessary to soften and resolve the postoperative scar so that the elasticity of the palate is not lost. For this purpose, a special type of massage is used - with a sound probe. It is moved with careful touches in the anteroposterior direction and back along the hard palate. They also use the technique of stroking and rubbing the area between the soft and hard palate in the transverse direction. This technique causes a reflex contraction of the muscles of the pharynx and soft palate. The next technique is massage with the sound a in the form of light pressure on the soft palate.
Finger pressure using point and jerk movements is also effective. The duration of the massage procedure is 1.5–2 minutes. During this time, 40–60 quick movements across the palate should be made. The massage is carried out twice a day before meals (1.5–2 hours before) or after with the same interval. The duration of the massage course is from 6 to 12 months. A very important point in the postoperative period are measures to activate the soft palate. For this purpose, the following sets of exercises are used. Gymnastics for the palate
1. Swallowing small amounts of water. In this case, the soft palate occupies the highest position. The throats, following one after another, keep the palate high for some time. For younger children, use a pipette and drop water onto the tongue. Older children are encouraged to pour water onto their tongue from a bottle or small cup.
2. Yawning with your mouth open, imitating yawning.
3. Light cough. At the same time, the muscles of the Passavan roller intensively contract. It can be 4–5 mm in size and in this condition compensate for velopharyngeal insufficiency. When coughing, the nasal and oral cavities are completely closed. The child can feel these movements if he places his palm and fingers on the chin area.
It is recommended to do 2-3 or more voluntary coughs on one exhalation.
The closure of the palate and the back wall of the pharynx is maintained at this time, while the air stream leaves the oral cavity. At the initial stages, it is better to cough with your tongue sticking out.
Then - coughing with stops, during which the child must try to keep the palate and the back of the throat closed. Over time, the child acquires the ability to actively lift the palate and exhale through the mouth.
It is recommended to pronounce vowel sounds clearly, with emphasis (on a firm attack), with a high timbre of the voice.
This increases resonance in the mouth and reduces the nasality of the sound.
All of the above correction methods bring positive results both before and after surgical treatment.
Long-term, systematic classes prepare the child for surgery and reduce the duration and complexity of the postoperative correction period.
Working on breathing
It is necessary for the formation of correct sound speech. Children with rhinolalia have a very short airflow output, which is distributed through the nose and mouth. To form a functional air outlet, the following techniques are used:
1) inhale and exhale through the nose;
2) inhale and exhale through the mouth;
3) inhale through the mouth;
4) exhale through the nose;
5) inhale and exhale through the mouth.
If the exercises are performed correctly, regularly, for a long time, the child feels a change in phonation and tries to correctly direct the exhaled air flow. These exercises also form the normal kinesthetic sensations of movements of the soft palate. When performing these exercises, it is necessary to help the child control himself, since it is quite difficult to feel some of the air escape through the nose. To help with this, various methods are used - placing a mirror to the nose or a piece of cotton wool or thin paper. Sometimes a set of corrective exercises includes playing children's wind instruments. These are very complex and tiring exercises for a child, not always advisable, causing fatigue faster than other techniques.
At the same time, another set of exercises is performed in order to normalize speech motor skills. Its daily use helps to reduce the high elevation of the tongue root, the lack of participation of the lips in articulation and increases the amplitude of movements of the tip of the tongue, as a result of which the pathological participation of the tongue root and larynx in sound pronunciation is reduced.
Gymnastics for lips and cheeks:
1) inflating the cheeks on both sides simultaneously;
2) inflating the cheeks alternately; retraction of the cheeks between the teeth into the oral cavity; performing sucking movements - stretching the closed lips with the “proboscis” forward and returning to the starting position. When performing this exercise, it is necessary to close the jaws;
3) grinning - maximum stretching of the lips in all directions with exposure of the teeth;
4) “proboscis”, then baring of teeth with closed jaws;
5) grinning with opening and closing of the oral cavity, then closing the lips;
6) grinning in an open mouth position, then lowering the lips onto the teeth of the lower and upper rows;
7) formation of a “funnel” (simulating a whistle);
8) retraction of the lips into the oral cavity with tight pressing to the teeth;
9) raising the lips while squeezing them tightly up and down with the jaws closed;
10) raising the upper lip with exposure of the upper row of teeth;
11) pulling back the lower lip, exposing the lower teeth;
12) imitation of rinsing teeth (air pressure on lips), lip trembling;
13) movements of the “proboscis” to the right and left, rotation;
14) maximum inflation of the cheeks (trying to hold air in the mouth with the lips, thereby increasing the pressure in the oral cavity);
15) holding a pencil between the lips. Gymnastics for the tongue:
1) protruding the tongue in the form of a shovel, sting, tongue in a spread or pointed form;
2) turns of the maximally extended tongue to the right and left sides;
3) up and down movements of the root of the tongue. In this case, the tip of the tongue rests on the lower gum, and the root of the tongue moves;
4) suction of the upper surface of the tongue to the palate - with the jaws closed and then open;
5) the protruding, spread tongue connects with the upper lip, and then is retracted into the oral cavity, while touching the upper dentition and palate and touching the tip at the top of the soft palate, bending at the same time;
6) suction of the tongue to the upper alveolar processes when opening and closing the mouth;
7) advancement of the tongue between the teeth with the feeling that the incisors on top are scratching the back of the tongue;
8) the tip of the tongue licks the lips in a circular motion;
9) the tongue is extended as much as possible, the mouth is open, while the tongue rises and falls between the upper and lower lips;
10) the tongue is in the form of a sting, the mouth is open, movements of the tip of the tongue are up to the nose, down to the chin, to the upper and lower lip, upper and lower teeth, towards the hard palate and the bottom of the mouth;
11) the mouth is wide open, the tip of the tongue touches the upper and lower incisors;
12) the tongue is extended, alternately takes and holds the shape of a groove, a boat, a cup;
13) holding the tongue in the mouth in the shape of a cup;
14) biting the sides of the tongue with teeth;
15) the lateral surfaces of the tongue are pressed against the upper lateral teeth; when grinning, the tip of the tongue touches the upper and lower gums;
16) tongue in the previous position, the tip of the tongue repeatedly taps the base of the upper teeth (as when pronouncing the sound t);
17) repetition of the exercise - the tongue is in the shape of a sting, a cup, a boat, raising it alternately up, lowering it down, then moving it to the right and left. Voice exercises
They are carried out when pronouncing vowel sounds. The beginning of the exercises is with the vowels [a], [o], [u], [e]. These vowels are then included in the gymnastics complex and repeated daily. Vowel production begins in silent mode. This is done in order to eliminate additional auxiliary facial expressions (movements of the wings of the nose), which is present in many children.
Exercises are carried out in front of a mirror, first silently, and then in a loud voice with a gradual increase in the number of vowels with one exhalation: [u] - [uu] - [uuu]; [a] – [aa] – [aaa]; [i] – [ii] – [iii], etc.
The next step is to pronounce the vowels in different sequences. In this case, the sounds are pronounced briefly and clearly. In addition to developing correct articulation, this exercise helps fill in the combination and sequence of sounds. In the future, the child should make small pauses between vowels, during which the soft palate should be maintained high. Pauses must be gradually lengthened from 1 to 3 s.
It is also necessary to include in the complex a long pronunciation of vowels one after another without pauses [a] - [i] - [u] - [e], etc.) in different sequences.
When practicing the correct pronunciation of sounds, an important and specific point is to constantly monitor the direction of the air flow. In cases of difficulty, you can temporarily close the nasal passages so that the articulation of sounds is more sonorous and clear. Specific to this correctional gymnastics complex is the order of the consonants. The sound [f] is placed first - unvoiced, fricative. Its placement is facilitated after exercises on the release of an air stream through the oral cavity. The sound is pronounced first in isolation, then as part of syllables, with a vowel placed both before [f] and after ([af] - [fa] - [afa], etc.). Exercises with puffing out the cheeks make it easier to produce the sound p, since when performing these exercises, the velopharyngeal seal is formed. Next, the child must perform a burst of lip closure to pronounce the sound p. If this movement is difficult, the speech therapist helps the child. The help is to move the lower lip down, while the child’s lips need to be opened. A sufficient explosion occurs when an air stream exits through the mouth, bypassing the nasal cavity. Staging and pronouncing a sound is used as one of the exercises that eliminates the nasal tone of the voice.
Producing the sound [t] requires correct exhalation through the mouth. In this case, the tip of the tongue is pressed against the upper teeth. The articulatory gymnastics carried out earlier makes sound articulation prepared and automated, and all stages of articulation are activated when there is sufficient oral air flow.
Articulation of the sound k is often difficult and is not always successfully pronounced in imitation. Coughing exercises do not help in all cases. Therefore, sound production can be done mechanically.
Speech therapy lessons at the preoperative stage help to avoid serious pathological disorders in the functioning of the speech organs.
In addition, they activate the soft palate, promote the physiological position of the tongue root, strengthen the work of the lip muscles, and shape the direction of oral exhalation.
These positive results influence the success of surgical treatment and the subsequent correction period.
2–3 weeks after surgery, repetition of some exercises is resumed in order to achieve elasticity and mobility of the closure.
Postoperative scars on the soft palate can reduce (tighten) the length of the soft palate. To stretch a fresh scar, exercises that simulate swallowing are used. At the same time, a massage course is prescribed.
The purpose of classes in the postoperative period is to increase the mobility of the soft palate and prepare for the pronunciation of sounds without nasality.
Criteria of L. I. Vansovskaya. With their help, it is possible to clearly separate combined speech disorders in children with rhinolalia and evaluate the correction carried out in two main areas - elimination of nasality and articulation disorders.
Speech is assessed based on the following criteria.
1. Normal and close to normal, i.e. there is a clear and physiological sound pronunciation and nasality is eliminated.
2. Significant improvement in speech - sound pronunciation is formed, moderately pronounced signs of nasality are present.
3. Improvement of speech - there is a formed articulation of some sounds with a moderate nasal sound.
4. Without improvement – there is no articulation of sounds, there is hypernasalization.
The results of correction are influenced by the following factors: the age at which surgical treatment was performed, the quality of the operation, the start of speech therapy assistance, the duration of training, and the help of family members. It is recommended that some of the most correctly performed exercises be repeated at home.
Closed rhinolalia. This defect is formed when the physiological nasal resonance decreases during sound pronunciation. The strongest resonance is for the sounds [m], [n]. Normally, when they are pronounced, the nasopharyngeal shutter is open and a stream of air enters directly into the nasal cavity. In the absence of nasal resonance for these sounds, they sound like oral sounds [b], [d].
The causes of this form of rhinolalia are in most cases organic changes in the nasal cavity or functional disorders of the velopharyngeal closure.
According to M. Zeeman, there are two types of closed rhinolalia (rhinophonia) - closed anterior, which occurs as a result of obstruction of the nasal cavities, and closed posterior, which is formed when the oral cavity decreases.
The result of corrective work to eliminate rhinolalia is determined by a number of factors: the condition of the nasopharyngeal cavities, the function of the uvula, and the age of the child.
Particularly important measures to solve this serious problem can be considered early prevention and comprehensive corrective action, which can reduce the development of pathology and accelerate social rehabilitation of patients with congenital anomalies of the palate.
CHAPTER 4. ACOUSTIC DYGRAPHIA
Acoustic dysgraphia is a partial specific writing disorder that occurs against the background of insufficient or distorted perception of the speech signal. Dysgraphia is characterized by persistent and repeated errors, expressed in the mixing and replacement of consonant oppositional letters, distortion of the sound-syllable structure, disruption of the unity of spelling of individual words in a sentence, and agrammatism.
The writing process is formed at later stages of a child’s education, on the basis of correctly formed oral speech. With insufficient phonemic hearing and phonemic perception, the process of developing oral speech and, as a consequence, the writing process is difficult.
Human speech uses special kinds of sounds based on rhythmic sound structures. These sounds (or phonemes) are organized into the phonemic system of the language. To distinguish them, it is necessary to encode sounds according to a given system, to isolate semantic phonetic features from a number of unimportant ones. To recognize human speech, during the process of phylogenesis, special sections were formed in the cerebral cortex that perform an analytical-synthetic function. The areas responsible for distinguishing speech sounds are grouped in the temporal regions of the cerebral cortex. They are divided into primary sections, responsible for elementary hearing, and secondary sections, responsible for the differentiation of complex sound complexes. Thus, with unilateral damage to the primary parts of the auditory cortex, a decrease in the acuity of auditory perception is observed, and with damage to the secondary parts of the temporal cortex (primarily the dominant hemisphere), disturbances in the perception of phonemes and memorization of speech material are observed. The presence of normal physical hearing is necessary for the formation of phonetic hearing and phonetic perception. The most difficult phonemes to perceive are acoustically close phonemes.
Acoustics studies the process of speech formation and the perception of speech signals in humans, considers the structure of the speech signal, its physical and mental characteristics.
Acoustics includes parameters such as:
1) vocality – vowels and sonorant consonants;
2) non-vocality – noisy consonants;
3) consonance – all consonants, including sonorant and noisy ones;
4) non-consonant – all vowels;
5) high pitch - sounds with a high vibration frequency. These include all front vowels, dental and anteropalatal consonants, as well as the mid-palatal C];
6) low tonality – sounds with a low vibration frequency. These include all other sounds;
7) interruption - all stops (characterized by a sharply broken edge of the wave, preceded by a period of complete silence), with the exception of nasals;
8) continuity;
9) sonority;
10) deafness.
The acoustic classification of sound complements the articulatory classification, characterizing the sound itself directly, thereby delimiting the pronunciation of phonemes that are similar in articulatory structure.
When phonemic hearing and phonemic perception are impaired, the acoustic criteria of human speech undergo qualitative changes. In expressive speech, not only distortions of sounds are observed, but also their omissions and replacements. At the level of phrases and sentences, there is a merging of two words into one, a violation of the sequence of words in a sentence, etc. In neurophysiology, the relationship between phonemic perception and expressive speech is explained as follows. Acoustic information from the peripheral auditory areas enters the Wernicke's center, which is located in the posterior third of the superior temporal gyrus. Here the analysis and synthesis of received information takes place.