I have a 4 year girl coming in for treatment of hypernasality. They girl has cleft lip and palate. Two surgeries have already been done, but I can see fistula behind alveolar ridge as well as her soft palate is incomplete. As in its V in shape and lot of roof area is uncovered at the back of the mouth.  I asked the parents and they reported that the doctor has told them that the girl doesn’t need any more surgeries and that the gap will recover/grow in some time. I haven’t seen many client’s with cleft in my work career. Can you please guide me in this regard? Am I going to take her hypernasality as a structural cause? If yes, where should I refer them .. to ENT, cleft team or to Dentist for prosthesis?

• ASHA advises that all cleft palate children be followed by a cleft palate team (which should have an SLP).  Suggest that first if it’s available because the SLP will be able to tell you the status of speech for her
• If you don’t have access to that, see what sounds the child can make in isolation.  Give placement and tactile cues as necessary.  Sometimes kids can compensate for structural problems in ways that don’t seem possible.  Just see if she can do it first.  You may want to do this for about 6 weeks to get a very good idea of what the child can and can’t do.
• If there are physical limitations that prevent her from saying certain sounds, bring that to the attention of the mother. Tell her that a cleft palate specialist could help with advising about additional surgeries or prostheses that could be used.
• In the meantime, advise the Mom that you will be doing therapy on the sounds you can and teaching compensatory placements as needed.

http://www.speechandlanguagekids.com/overview-of-therapy-for-cleft-lip-and-palate-children/