CASE STUDY: The ‘impossible lisp’ ENT, Orthodontist & Speech Pathology Team Management
Managing the complexity of a lisp, narrow palate and tongue thrust, chronic nasal allergies and a husky voice. As with many things, these were all linked… And as a part of the treating team, we had to find the best way to assist James and his family.
Why James came to speech pathology
James’s orthodontist had identified a tongue thrust and recommended speech pathology prior to orthodontic treatment to treat a narrow jaw. James also had a lisp.
“Parent quote here”
His Managing Team:
- Speech Pathology
At the time that James came to see us, he had previously been to see ENT for a snuffly nose and had been recommended nasal sprays; antibacterial and corticosteroids but James was very reluctant to use them as he reported that they tasted bad in the back of his throat. James had previously had a tongue tie released as an infant, and had had his tonsils and adenoids removed 2 years earlier. James was also a thumb sucker and did not have much motivation to stop.
Speech Pathology Clinical Assessment
Our initial speech patterns assessment identified a moderate interdental lisp where James says /s/ sounds by protruding his tongue slightly between his front teeth. This speaking behaviour also affected his /z/ sounds which sounded more like a buzzy /th/ sound, e.g. ‘is’ was said like ‘ith’. James also confused /th/ sounds as /f/ sounds, e.g. ‘thumb’ would be said as ‘fumb’, which while common at his age is no longer an expected speech behaviour.
Assessment of James’s mouth structures (anatomy and physiology) showed that he had an exceptionally high hard palate. The hard roof of your mouth usually has a gentle curve. In Ethen’s case, both sides rose at a steep angle upwards meeting in the midline in a ‘v’ shape.
Normally, a tongue’s natural resting position is sit in the mouth sealed against the roof.
Your oral structures form in response to your musculature. James’s tongue was not able to rest with a seal against the roof of his mouth.
Physiologically, James had a very prominent tongue thrust. This means that when he swallowed, instead of his tongue pushing itself upwards to the roof of the mouth to push any food or drink backwards, his tongue would dart forwards pushing out slightly between his teeth.
This was not observable by anyone except if you opened his lips when he was swallowing. Over time, the constant push on your tongue against your the back of your front teeth on each of the 2000 occasions that you swallow per day will gradually shape your upper jaw and front teeth pushing them into a protruding position.
James’ upper front teeth were already in a mildly forward position. He was due for orthodontic management, however, his underlying tongue thrust would still need to be corrected otherwise this behaviour would continue to undermine any treatment he had.
We also observed that James had a reasonably husky voice with a hyponasal quality, as if he’d had a recent cold, talking with a slightly blocked nose. His parents reported that as far as they could tell, his voice was always like this. A husky voice should never be typical for a child. Given it was autumn and there were plenty of bugs going around and the other things we had to focus on, this was the priority of treatment more for monitoring.
Speech Therapy – 6 months
We started James off with an intensive tongue thrust program which entailed teaching him an awareness of his tongue and its location and behaviours in his mouth using playdoh, model mouths, video recordings of his swallow and reviewing the footage. We do this with all children and adults as most of us, unless specifically taught, do not really think about the size of our tongue, what it is doing at various points of the swallowing process. Swallowing is just swallowing – you pop food in and you swallow it down, right? The key to success in tongue thrust management is for a client to have a clear understanding of what is happening in their mouths and as well as clear understanding of the desired goal even the very young children we treat. This is because their tongue behaviours when swallowing are hidden as their mouths are closed (obviously!) so the prep before we start is imperative, and they can give us clear feedback about what they re doing. The first 6 weeks concentrated on James learning how to swallow with his tongue in the ‘magic spot’ on the ride behind his front teeth. His earnestness was incredible, at times his fight to keep his tongue tip in the correct position while the remainder of his tongue would use their ‘old’ behaviour meant that the bulk of his tongue would have outwards. The tongue is made up of more than 20 layers of muscles and trying to out-train a muscle behaviour that you have done all your life takes a lot of awareness and commitment.
We move to work on James’s /s/ and /z/ speech sounds. We started with the /s/ sounds. Most people produce the /s/ sounds with their tongue tip pointing upwards while some have their pointing downwards. I have found that when a child has a lisp, it is harder to pull the tongue inwards keeping it pointing upwards then point it downwards. It seems harder to tweak something you are already doing than try something entirely new. There is not much that is ‘magic’ about speech pathology, but in almost all cases by changing the tongue tip positioning to anchoring it deep behind lower front teeth we are able to get almost instantaneous results – even with children who may have previously seen other therapists for a couple of years or more to work on /s/ sounds. James was able to position his tongue in the correct position straight away getting wobbly clear /s/ sound. It would take 2 weeks for James to consistently manage the airflow over the top of his tongue and behind his teeth. From there we rapidly stepped up therapy goals each week moving through using /s/ sounds in different positions in words; beginning, end, middle, in clusters such as ‘st’ ‘sl’ ‘sm’ in all word positions on their own, in phrases, sentences and in free conversation. This took another 4 months of weekly therapy. We tried to drop to fortnightly sessions prematurely but found that without the weekly touch point James’s lisp behaviours would return. James is a very high energy – therapy games involved competition style dynamic activities including basketball, nerf gun wars, obstacle courses and other activities racing against the clock. James’s home practice program was low dose but high frequency, which essentially means ‘little and often’. This was logistically challenging for a family where both his parents worked full time. We worked hard with James and his family to make activities as functional as possible.
“Parent quote here”
A Whole Team Approach
We reached a point where James’s /s/ and /z/ sounds accurate in structured tasks 90% of the time, and accurate conversational speech 70% of the time. James’s voice had remained husky continuously in this period always sounding as though his nose was blocked with mucus. James was a mouth breather. He was unable to inhale more than 4 breaths through his nose before needing to breathe through his mouth. As such, his tongue did not have an easy resting position in his mouth. It reached a critical point where we felt that he would not make further progress with his tongue thrust therapy as he was not able to rest his tongue in his mouth. After discussions with James’s parents, we reached out to ENT and Orthodontist for a team management approach. Our thoughts were that James’s husky voice was being caused by a continuous post-nasal drip (mucus dripping from his nose) on to his vocal cords causing irritation affecting his voice. Our key priority now was to try and manage James’s allergies. If this was possible through nasal sprays, this would mean that James would be able to breathe through his nose and potentially be able to close his mouth and so we could train his tongue to rest within his mouth. There was also the potential for James to need nasal scraping. We worked with James and his family to assist daily use of his nasal sprays as per ENT advisement. The orthodontic approach would require fitting a plate to widen his palate. Bringing the palate downwards would also open up the nasal cavity hopefully ease of breathing. By this point, James’s speech had reached a level of consistency that we were confident that a break from speech pathology would not mean that it would overly regress. This team approach indicated that the priority in James’s treatment should switch to orthodontics with speech pathology resuming after 4-6 weeks after the plate has been fitted.
Outcome to date
- James has almost conversational use of clear /s/ and /z/ sounds and starting to use /th/ sounds accurately.
- We await the phase 1 of the orthodontic treatment to be finished before we resume speech pathology for tongue thrust.
|Example Therapy Activities:||Nerf gun wars, Jenga, Connect 4, Trick Sticks, Don’t Wake the Dog, obstacle Course, basketball, races|