Palatopharyngeal closure of the component is a function of impairment. Causes and mechanism of speech impairment in rhinolalia: modern approaches

To understand the mechanism of occurrence of these anomalies, one should study the process of lip and palate formation.

The formation of the lip and palate begins at 5-10 weeks of intrauterine life; there is a division of the primary oral cavity into two sections:

oral cavity and nasal cavity.

This is due to the formation of lamellar protrusions of the palatine processes on the inner surfaces of the maxillary processes. At the beginning eighth week the edges of the palatine processes are directed obliquely downward and lie along the bottom of the oral cavity, on the sides of the tongue. The lower jaw is enlarged. The tongue descends into this space, making it possible to move the palatine processes from a vertical position to a horizontal one.

At the end second month the life of the embryo, the edges of the palatine processes begin to connect with each other, begins in the anterior sections and gradually spreads posteriorly. The septum of the mouth bay is the rudiment of a hard and soft palate. It separates the final oral cavity from the nasal cavity. At the same time, the growth of the nasal septum occurs, which grows together with the palate and divides the nasal cavity into the right and left nasal chambers.

by the 11th week, a lip and a hard palate are formed,

and by the end of the 12th week, fragments of the soft palate grow together with each other. The condition of the lip and palate in the embryo at individual stages of development is the same as in nonunions observed in the clinic: from a through bilateral fissure defect of the lip, alveolar ridge and palate to nonunion of only the soft palate and even only the uvula or latent nonunion of the lip. Conventionally, this condition of the lip or palate can be called a physiological cleft. Under the influence of one or more of the listed etiological factors, the fusion of the edges of the "physiological clefts" is delayed, which leads to congenital nonunion of the lip, palate, or a combination of them.

One of the pathogenetic factors of non-union of the halves of the palate is obviously the pressure of the tongue, the size of which, as a result of the discorrelation of growth, turned out to be larger than usual. Such a discrepancy can arise on the basis of hormonal metabolic disorders in the mother's body.

Topic 3. Causes and mechanisms of disorders in rhinolalia

.Rhinolalia reasons.

Types and forms of congenital clefts.

Classification of rhinolalia.

The mechanism of occurrence of speech disorders in rhinolalia.

Mechanisms of impairment of speech breathing, voice formation and sound pronunciation.

Etiology

Etiological factors of anomalies in the human body, including the maxillofacial region, are divided into exogenous and endogenous.

TO exogenous factors relate:

1) physical (mechanical and thermal effects; external and internal ionizing radiation);

2) chemical (hypoxia, malnutrition of the mother during critical periods of embryo development, lack of vitamins (retinol, tocopherol acetate, thiamine, riboflavin, pyridoxine, cyanocobalamin), as well as essential amino acids and iodine in the mother's food; hormonal discorrelations. Effects that are teratogenic poisons cause fetal hypoxia and deformities in it, the influence of chemical compounds that mimic the effect of ionizing radiation, such as mustard gas;

H) biological (measles viruses, mumps, shingles, bacteria and their toxins);

4) mental (cause hyperadrenalinemia).

TO endogenous factors belong to:

1) predisposition to pathological heredity (there is no gene carrying a hereditary predisposition to non-union)

2) biological inferiority of cells;

H) the influence of age and gender.

In the history of patients and their parents, it is often possible to establish the following factors, with which the appearance of birth defects has to be associated: infectious diseases transferred by the mother during pregnancy; toxicosis, spontaneous and induced abortion; severe physical injury at 8–12 weeks of gestation; diseases of the genital area; severe mental trauma to the mother; late childbirth; malnutrition of the mother.

Types and forms of congenital clefts

Congenital underdevelopment of the palate includes:

1) congenital cleft palate and lips

2) submucosal clefts;

3) congenital underdevelopment of the palate;

4) congenital asymmetry of the face with deformation of the palate.

Most often in practice, there are clefts of the lip and palate. The forms of palatine clefts are extremely diverse, but they all lead to speech impairment.

Cleft lips. Distinguish between partial and complete cleft lip. The anatomical structure and size of the lips in children and adults vary considerably.

A normally developed upper lip has the following anatomical components:

1) filter 2) two columns; H) red border; 4) the median tubercle; 5) the line, or arc, of Cupid. This is the name of the line dividing the red border and the skin of the upper lip.

When treating a child with a congenital lip defect, the surgeon must recreate all of its listed elements.

Classification. In accordance with the clinical and anatomical features, congenital defects of the upper lip are divided into several groups.

1.non-union of the upper lip is divided into lateral - unilateral(accounting for about 82%), bilateral.

2.on partial(when the non-union has spread only to the red border or at the same time with the red border there is a non-union of the lower part of the skin part of the lip

and full- within the entire height of the lip, as a result of which the wing of the nose is usually deployed due to non-union of the base of the nostril

Cleft palate. The palate is normally a mass that separates the mouth, nose and throat. It consists of a hard and soft palate. Solid has a bone base. In front and on the sides, it is framed by the alveolar process of the upper jaw with teeth, and behind it is the soft palate. The hard palate is covered with a mucous membrane, the surface of which behind the alveoli has an increased tactile sensitivity. The height and configuration of the hard palate affects resonance.

The soft palate is the posterior part of the septum between the cavities of the nose and mouth. The soft palate represents muscle formation. The front third of it is practically motionless, the middle one is most actively involved in speech, and the back one in tension and swallowing. Ascending, the soft palate lengthens. At the same time, there is a thinning of its anterior third and a thickening of the posterior one.

The soft palate is anatomically and functionally connected with the pharynx, the palatine-pharyngeal mechanism is involved in breathing, swallowing and speech.

When breathing, the soft palate is lowered and partially covers the opening between the pharynx and the oral cavity. When swallowing, the soft palate stretches, rises and approaches the back wall of the pharynx, which accordingly moves towards and comes into contact with the palate. At the same time, other muscles contract: the tongue, the lateral walls of the pharynx, its upper constrictor.

When blowing, swallowing, whistling, the soft palate rises even higher than during phonation, and closes the nasopharynx, while the pharynx narrows.

Foreword

Elimination of the consequences of congenital cleft lip and palate involves the correction of speech disorder, which is a component of the clinical picture of the main somatic defect. In this case, a violation characterized only by an increase in nasal resonance of the voice is classified as open rhinophonia, and including also distorted sound production - as rhinolalia.

According to the classification of the World Health Organization, rhinophonia and rhinolalia are classified as voice disorders. It is the unbalanced resonance that provokes the development of all other pathological changes in the phonetic side of speech. With congenital clefts of the palate or palatopharyngeal insufficiency, the nasal cavity becomes a paired resonator of the oral cavity. In accordance with the laws of acoustics, the oscillation frequency of this paired resonator is superimposed on the oscillation frequency of the fundamental tone. As a result, the acoustic spectrum of the voice changes significantly. Additional nasal formants appear in it. Nasal resonance or open nasalization deprives the voice of resonance and flightiness. The voice becomes monotonous, nasal, deaf.

But if during rhinophonia only the acoustic side of speech is disturbed, then with rhinolalia, deviations in the aerodynamic conditions of speech production are added to this: changes in the direction of air flows in the oral and nasal cavities, a decrease in air pressure in the oral cavity. Adaptation to the existing conditions leads to gross distortions of articulations.

Pathophysiological studies in recent years have revealed many detailed features of respiration, voice formation and articulation in rhinophonia and rhinolalia, but only a small part of them have found application in speech therapy.

This has led to conflicting recommendations for correcting rhinophonia and rhinolalia. In addition, the available literature is represented by a large number of scientific articles, each of which is devoted to a certain pathological symptom and methodological techniques only for its correction.

The main objective of this manual is a consistent presentation of the methodology of correctional and educational work to correct the phonetic side of speech in rhinolalia. In the course of the theoretical and practical development of the issue, methods were used to restore the voice for various violations (A.T. Ryabchenko, E.V. Lavrova), certain techniques of vocal pedagogy (V.G. Ermolaev, N.F. Lebedeva, L.B. Dmitriev), research materials and guidelines of domestic and foreign phoniatrics and speech therapists (E.F. Pay, Z.G. Nelyubova, M. Morley, M. Green, A.G. Ippolitova, T.N. Vorontsova, L.I. . Vansovskaya, D. K. Wilson). Our own long-term practical experience has confirmed the effectiveness of the proposed methodology.

The manual consists of five sections, didactic material, a list of recommended literature and appendices.

The first section describes the anatomical and functional role of the palatine-pharyngeal apparatus in normal conditions and disorders caused by congenital clefts of the palate. Particular attention is paid to the characteristics of the phonetic side of speech in rhinolalia.

The second section sets out the basics of step-by-step correctional and pedagogical work to correct rhinophonia and rhinolalia before and after plastic surgery of the palate.

The third section is devoted to the method of setting physiologically correct voice-leading and correction of voice disorders in congenital clefts of the palate by phonopedic methods.

In the fourth section, separate techniques for setting sounds for rhinolalia are analyzed.

The didactic material contains isolated words, phrases, sentences, poems and short stories that can be used to correct the sound pronunciation of children with rhinolalia.

The appendix contains complexes of respiratory and mimic gymnastics for children with congenital clefts of the palate.

Anatomical and physiological features of the palatine-pharyngeal apparatus in health and disease

Congenital cleft palates are one of the most common malformations of the face and jaws. It can be caused by a variety of exogenous and endogenous factors affecting the fetus at an early stage of its development - up to 7-9 weeks.

The palate is normally a mass that separates the mouth, nose and throat. It consists of a hard and soft palate. Solid has a bone base. In front and on the sides, it is framed by the alveolar process of the upper jaw with teeth, and behind it is the soft palate. The hard palate is covered with a mucous membrane, the surface of which behind the alveoli has an increased tactile sensitivity. The height and configuration of the hard palate affects resonance.

The soft palate is the posterior part of the septum between the cavities of the nose and mouth. The soft palate itself represents muscle formation. The front third of it is practically motionless, the middle one is most actively involved in speech, and the back one in tension and swallowing. Ascending, the soft palate lengthens. At the same time, there is a thinning of its anterior third and a thickening of the posterior one.

The soft palate is anatomically and functionally connected with the pharynx, the palatine-pharyngeal mechanism is involved in breathing, swallowing and speech.

In the process of speech, a very rapid muscle contraction is constantly repeated, which brings the soft palate closer to the posterior wall of the pharynx in the direction upward and backward. When lifted, it comes into contact with the Passavan roller. However, there are conflicting opinions regarding the indispensable participation of the latter in the palatopharyngeal closure in the literature. In practice, it is quite rare to observe the formation of Passavan's roller in persons with cleft palates. The soft palate moves up and down very quickly during speech: the time for opening or closing the nasopharynx ranges from 0.01 to 1 second. The degree to which it is raised depends on the fluency of speech, as well as on the phonemes that are being pronounced at the moment. The maximum lifting of the palate is observed when pronouncing sounds a and s, a its greatest stress at and. This voltage decreases slightly at at and significantly on oh, uh, uh

In turn, the volume of the pharyngeal cavity changes with the phonation of different vowels. The pharyngeal cavity occupies the largest volume when pronouncing sounds and and y, smallest at a and intermediate between them at NS and O.

When blowing, swallowing, whistling, the soft palate rises even higher than during phonation, and closes the nasopharynx, while the pharynx narrows. However, the mechanisms of the palatine-pharyngeal closure during speech and non-speech activity are different.

There is also a functional connection between the soft palate and the larynx. It is expressed in the fact that the slightest change in the position of the palatine curtain affects the position of the vocal folds. And an increase in tone in the larynx entails a higher rise in the soft palate.

Congenital clefts of the palate disrupt this interaction.

In their appearance, the defects of the palate are varied. There are many classifications of this defect in the literature. However, all forms of clefts can be reduced to two main ones: through and isolated.

Isolated crevices divide the palate in half. They can capture only a small uvula, part or all of the soft palate, and even reach the alveolar ridge, which itself remains intact. The palatine curtain in these cases is shortened, and its segments are pulled apart. A variety of isolated crevices are submucosal (submucous) clefts hard palate. They are usually combined with shortening and thinning of the soft palate. Submucosal cleft can be detected when pronouncing a vowel a. In this case, the mucous membrane is drawn into the defect in the form of a concave triangle, which is clearly visible.

At through crevices the integrity of the alveolar process is also violated. These defects are one-sided and two-sided. Usually they are accompanied by clefts of the lip.

In bilateral clefts, before the operation, the incisor bone is advanced forward and may even occupy a horizontal position.

In such cases, it is often necessary to deal with a violation of the dentition: incorrect position of the teeth, damage to their caries, excessive or insufficient number. The bite is also very variable. Progeny, less often prognathies, open bite, diastema are observed.

The cleft palate is usually shortened and stunted compared to the normal palate even after uranoplasty.

The functions of the soft palate are impaired due to the lack of communication between the paired muscles. During phonation and swallowing, they spread the segments of the soft palate to the sides. After the operation, his mobility does not reach the norm due to the fact that the muscles lifting him are attached not at the level of the middle third, as in the norm, but far in front.

The anatomical defect causes breathing, nutrition, phonation, speech and hearing disorders. Rinolalia significantly aggravates the effect of hearing impairment on the phonetic structure of speech.

Respiration changes with clefts are versatile. Due to the lack of differentiation between the cavities of the nose and mouth, children constantly use mixed nasal-oral breathing, in which the duration of exhalation is sharply reduced. Breathing becomes quickened, the vital capacity of the lungs decreases, the chest lags behind in development, and its excursion decreases.

Phonation respiration suffers deeply. It is known that people normally breathe through their mouths during speech. In this case, the inhalation is shortened, becoming deeper, the exhalation is lengthened and 5-8 times longer than the duration of the inhalation, and the number of respiratory movements per minute is reduced from 16-20 to 8-10; the abdominal wall and internal intercostal muscles are actively involved in the speech exhalation, which helps to lengthen the exhalation and provide sufficient sub-lining pressure.

Children with cleft palates, when talking, continue to breathe simultaneously through their nose and mouth with an exclusively clavicular type of breathing. When they exhale, a significant volume of air (on average 30%) flows into their nose, which, firstly, sharply shortens the duration of exhalation and, secondly, lowers the air pressure in the space above the fold. Therefore, phonation breathing remains rapid and shallow.

In an effort to reduce air leakage into the nose and maintain the pressure necessary for consonant sounds, children tighten their forehead muscles and squeeze the wings of the nose.

These compensatory grimaces gradually become a habit that accompanies speech, and become characteristic of individuals with rhinolalia.

Other changes in timbre are associated with the unification of the cavities of the nose, mouth and pharynx into one, with the peculiarities of the configuration of resonators with pronounced scars after uranoplasty, with the presence of additional folds of the mucous membrane, and restriction of mouth opening.

Lack of integrity of the palatine curtain, limitation of its mobility and pathological changes in the pharyngeal muscles disrupt the coordination of movements of the larynx and palate. As a normal vocal reflex pathogen due to the abundance of afferent innervation, the palatine curtain and the posterior part of the pharynx cannot provide this function with clefts. However, attention is drawn to the fact that the acoustic qualities of the voice of children with cleft palates in the first year of life do not differ from the voice with a normal structure of the upper jaw. In the pre-speech period, these children scream, cry, walk in a normal child's voice. The change in the timbre of their voice - open nasal resonance - appears for the first time during babbling, when the child begins to articulate his first consonant phonemes.

Later, until about seven years of age, children with congenital clefts of the palate speak (both before and after plastic surgery) in a voice with nasal resonance, but clearly not different from normal in other qualities. Electroglottographic examination at this age confirms the normal motor function of the larynx, and myography confirms the normal reaction of the muscles of the pharynx to an irritant, even with extensive defects of the palate.

After 7 years, the voice begins to deteriorate: strength decreases, exhaustion, hoarseness appears, and the expansion of its range stops. An asymmetric reaction of the pharyngeal muscles is found on the myogram, a thinning of the mucous membrane and a decrease in the pharyngeal reflex are visually observed, and changes appear on the electroglottogram, indicating the uneven work of the right and left vocal folds. That is, there are all the signs of a disorder of the motor function of the voice-forming apparatus, which is finally formed and consolidated by the age of 12-14. Adolescents and adults with rhinolalia in almost 80% of cases suffer from voice disorders. Phononasthenia or paresis of the internal muscles of the larynx are specific for them.

There are three main causes of voice pathology in congenital clefts of the palate.

Violation of the mechanism of the palatine-pharyngeal closure. Due to the close functional connection of the soft palate and the larynx, the slightest tension and movement of the muscles of the palatine curtain causes a corresponding tension and motor reaction in the larynx. In cleft palate, the muscles that lift and stretch it, instead of being synergistic, act as antagonists. At the same time, due to a decrease in the functional load in them, as in the muscles of the pharynx, a dystrophic process takes place. Pathological changes in the pharyngeal ring begin to appear at 4-5 years of age. The mucous membrane becomes pale, thinned, atrophic, stops responding to touch, pain, thermal stimuli. Muscle chronaxia lengthens with age, and then they stop contracting altogether. The pharyngeal reflex drops sharply and disappears. These symptoms indicate atrophy of muscle fibers and degenerative changes in the sensory and trophic fibers of the pharyngeal constrictor. The pathological dystrophic process in the muscles leads to their asymmetry and asymmetry of the resonator cavities of the larynx and asymmetric movement of the vocal folds.

Incorrect formation with rhinolalia of a number of voiced consonants in the laryngeal (guttural) way, when the closures are carried out at the level of the larynx and are sounded by air friction against the edges of the vocal folds. In this case, the larynx assumes, according to M. Zeeman, an additional function of the articulator, which, of course, does not remain indifferent to the vocal folds.

The development of the voice is influenced by the characteristics of behavior. Embarrassed by the deformity of the face and defective speech, not wanting to attract the attention of others, children get used to speak constantly quietly, without increasing the strength of their voice under any circumstances. Lack of training leads to the consolidation of a quiet sound.

Speech, which develops in pathological conditions, suffers more heavily than other functions in congenital clefts of the palate. In most cases, spontaneous speech correction after uranoplasty does not occur.

Due to the absence of palatal-pharyngeal closure, the nasal cavity becomes a paired resonator of the oral cavity, imparting the nasal timbre to all phonemes. The severity of nasal speech resonance depends on the lack of closure, mobility of the palatine curtain and coordination of movements of the tongue and soft palate. Nasalization can be severe or mild.

According to the severity of the violation of sound pronunciation and the degree of nasalization of speech, all children with cleft palates can be divided into three groups (according to M. Morley).

First group are children in whose speech there is nasal resonance, but consonants are formed with correct articulations. This disorder is classified as open rhinophonia. This group most often includes people with submucosal (submucous) clefts of the hard palate, incomplete clefts and shortening of the soft palate.

Second group make up persons with pronounced nasal resonance of speech and distorted articulation of consonants. They suffer from more extensive defects of the palate.

Have third group speech is characterized not only by pronounced nasal resonance, but also by an almost complete absence of consonant articulations. It only retains its rhythmic pattern. Such speech is characteristic of children under five years of age, whose sound pronunciation has not yet developed, as well as those in whom a cleft palate is combined with malocclusion, hearing loss and other abnormalities.

Speech of the second and third groups is classified as open rhinolalia. Its intelligibility averages 28.4%. The connection between the type of cleft and the severity of the violation of sound pronunciation is not direct. Distortion of phonemes depends on the size of the gap between the edge of the soft palate and the pharyngeal wall and in turn affects the degree of nasalization.

The development of defective articulations in rhinolalia is due to a number of factors. The pathological position of the tongue in the oral cavity has long been described: the flaccid, thinned tip of the tongue lies in the middle of the oral cavity, not taking part in sound production. A massive hypertrophied root covers the entrance to the pharynx.

The displacement of the body of the tongue to the pharynx is explained by the fact that only in the laryngopharynx does the pressure of the air column reach the value necessary for the formation of consonant phonemes. In the higher regions, due to air leakage into the nose, the pressure drops sharply, and breaking the bows or sounding gaps during the articulation of consonant phonemes becomes impossible.

In addition, leakage of air into the nose makes it much more difficult to form the directional air jet required for consonants in the mouth. Even if this stream is present, it is so weak that it cannot create a full-fledged phoneme. Voiceless consonants in such cases remain soundless, and voiced ones acquire the same vocalized sound without individual acoustic coloration.

Most often, there is no directed air stream at all, and children replace it with an increased exhalation from the pharynx. They form the bows and slits by the root of the drawn tongue and the posterior wall of the pharynx in the path of the air flow that came out directly from the larynx. This method of articulation is called pharyngeal or pharyngeal. With rhinolalia, they pronounce almost all plosive and fricative voiceless consonant phonemes.

For the formation of voiced consonant phonemes, they resort to another compensatory act, in which the cracks and bows descend to the level of the larynx. This method of sound production is called laryngeal or laryngeal.

Vowel sounds are also pronounced with a raised root of the tongue. The constant active participation of the root of the tongue in swallowing and articulations leads to its hypertrophy. There is no spontaneous displacement of the tongue to its normal position after surgery. Only speech therapy classes help to eliminate this deficiency. It is interesting that even with acquired defects of the soft palate even in adulthood, a similar compensation develops and the tongue is pulled back.

Deformations of the dento-jaw region, shortening of the hyoid ligament and cicatricial deformities of the lips also stimulate the development of pathological sound pronunciation. An open bite, progeny, prognathies, defects of the alveolar process interfere with the contacts of the lips, lips and teeth, tongue and teeth and do not allow the correct articulation of labial, labiodental and dentate consonants. Bilateral clefts of the alveolar process, in which the anterior section of it takes a horizontal position, do not allow the lips and teeth to be closed and completely exclude the possibility of articulation of the two-labial and anterior-lingual phonemes. The short sublingual ligament prevents the tongue from lifting for upper articulations, and the massive scars after cheiloplasty make it difficult to pronounce the two-lingual consonants. The mid-lingual-palatine and posterior-lingual-palatine sounds cannot be articulated due to the absence of one of the constituents of the bridge - the palate.

The acoustic characteristic of vowels is distorted with rhinolalia due to nasal resonance, which is enhanced by a change in the shape of the resonators and the rise of the back of the tongue. The severity of the nasal shade of each vowel is associated with the density of the palatine-pharyngeal closure, the degree of narrowing of the lips and the change in the shape of the pharynx. The smallest pharyngeal volume is observed with articulation of the phoneme a, and the largest - at and, at. Expansion of the pharynx in the absence, shortening or limitation of the mobility of the palatine curtain leads to an increase in the gap between the edge of the soft palate and the posterior wall of the pharynx. Clinically, this is expressed by an increase in the nasal shade with rhinophonia from a To at in sequence a- O - NS- and- at.

Articulation and acoustic qualities of consonant phonemes in rhinolalia are characterized by the most pronounced deviations. In the flow of speech, children skip sounds, replace them with others, or form them in a defective way. The most characteristic is the replacement of explosive and fricative pharyngeal (pharyngeal) and laryngeal (laryngeal).

Labial n, n ", b, b" are silent, or are replaced by exhalation, or articulated with such a strong nasal resonance that they turn, respectively, into mm or formed at the level of the pharynx (n, n ") or larynx (b, b "), turning into sounds similar to k, g.

Back-lingual k, g are formed in the same way, since the defect makes it impossible for the back of the tongue and palate to contact. Sound G there is also a fricative pharyngeal. Front-lingual t, t ", d, d" are weakened or replaced by n, n ", replaced by a laryngeal or pharyngeal ridge.

The overwhelming majority of children replace fricative consonants with pharyngeal, very similar-sounding formations. Lateral or double-lipped replacements are rare.

Disturbances of the nasal with rhinolalia are expressed most often in their replacement by unformed vocalization; phoneme l sometimes double-lipped, is replaced by j, n, and its soft pair is pronounced correctly more often than other sounds of the Russian language. Replace l " on j or n " or they miss it altogether.

In case of pharyngeal insufficiency, consonant phonemes p, p " they almost never achieve a normal sound, because the tip of the tongue needs a very strong jet pressure to vibrate, which, as a rule, cannot be achieved. Therefore, the sound is skipped, replaced by a one-hit or protested sound. After the operation, the formation of a velar p is also possible, when the edge of the soft palate vibrates during exhalation. With rhinolalia, voicing of consonants, especially phonemes, often suffers b, b ", d, d, h, h", g. They are replaced by dull vaporization.

After plastic surgery, children have mixed nasal-oral breathing, defective sound production, nasalized, inarticulate speech, a deaf, quiet voice. That is, speech by itself, without special training, is not normalized.

The reason for the durability of dyslalia lies not only in the strength of the links of pathological sound production. In people with cleft palates, a decrease in kinesthesia, a disorder of phonemic hearing and astereognosia of the tongue are the result of a decrease in air pressure in the oral cavity, which dulls the tactile perception of "explosions" and air currents. Orthodontic appliances and removable dentures, covering the mucous membrane of the palate and alveolar ridge, exclude important areas of the oral cavity from sensations. With age, kinesthetic sensations decrease more and more.

When studying phonemic hearing in children with cleft palates, certain features are also revealed. It is known that both auditory and speech-motor analyzers are involved in speech perception. In the central nervous system, there is a connection between the sound and motor images of the phoneme, which makes it possible to recognize it and highlight it. An organic violation of the peripheral end of the motor speech analyzer (cleft palate) inhibits its influence on the auditory perception of sounds. The development of auditory differentiation in children with rhinolalia is impeded by pathological stereotyped articulations, which give rise to the same kinesthesia, even with acoustically contrasting phonemes. The level of auditory differentiation is directly related to the depth of damage to the phonetic side of expressive speech.

In practice, one has to most often deal with a mixture of consonants of close acoustic groups in both expressive and impressive speech. This is also due to the fact that due to the limitation of the possibilities of the pharyngeal and laryngeal sound formations, all fricative and explosive phonemes sound the same. This similar sounding phoneme is anchored in the central nervous system. Many children consider themselves to be normal speakers and learn about their speech impairment from others.

A variety of opinions are given in the literature regarding the vocabulary and grammatical structure of speech with rhinolalia. Some authors point out that the degree of violation of writing and the lexical and grammatical structure of the language depends not only on the defeat of the articulatory apparatus, but also on speech education, the environment, the degree of hearing loss, and the characteristics of the personal and compensatory systems.

The issue of the level of development and correction of written speech and the lexical and grammatical structure of the language is a separate problem and therefore is not considered in this manual.

CORRECTING SPEECH IN CHILDREN AND ADOLESCENTS WITH CONGENITAL FRACTURES OF THE PALATE

Correctional and pedagogical work to correct rhinolalia provides for a strict physiologically grounded sequence. It does not depend on the child's age, the severity of the violation of the phonetic side of speech, the type of anatomical defect, its condition (before or after plastic surgery). First of all, measures are taken to compensate for the insufficiency of the palatine-pharyngeal seal. This prepares the anatomical and physiological basis for the normalization of speech. After that, all attention is paid to the setting of physiological and phonation respiration, since it is the basis for full-fledged voice formation, voice leading and sound pronunciation. Active palatal-pharyngeal closure and respiratory "support" allow us to start solving the main task - to eliminate excessive nasal resonance and develop physiological voice-leading skills with a balanced resonance in accordance with the norm of the Russian language. Only after this is it advisable to correct the sound pronunciation, since a strong directed air stream makes it possible to produce full-fledged sounds. Their introduction into a word or phrase on the basis of correctly organized breathing and voice-leading provides the possibility of developing a stereotype of normal speech. Speech therapists are very often seduced by the dubious prospect of correcting sounds as soon as possible. But the correction of articulations, carried out before the breath and voice are set, only improves the intelligibility of speech, while maintaining blurred consonants and excessive nasal resonance.

Correctional and pedagogical work to correct rhinolalia is based on the structural features of the articulatory apparatus before and after uranoplasty, the effect of restrictions on the functions of the palate and pharynx on sound production and voice formation, and the student's individual reaction to his condition. Depending on this, methodological techniques are individually selected.

However, for all, four general stages of work are accepted.

1. Preoperative preparatory stage.

2. Postoperative stage. Setting vowel sounds. Eliminate excess nasal resonance.

3. Stage of correction of sound pronunciation, coordination of breathing, phonation and articulation.

4. Stage of complete automation of new skills.

The duration of the stage is determined individually. Typical for each stage is the main focus of the work on solving a specific problem, although exercises corresponding to other stages can be used.

Targeted correction of rhinolalia should be started as early as possible - from the age of 3. Classes are held on an outpatient basis, at least twice a week.

First of all, it is necessary to carefully examine the child in order to identify the individual characteristics of speech development. Based on these data, an individual plan of correctional and educational work is drawn up.

The examination includes: 1) a description of the anatomical features of the structure of the entire articulatory apparatus and the congenital defect itself; 2) determination of the state of physiological and speech respiration; 3) identification of the features of sound pronunciation; 4) determination of the levels of general speech and intellectual development; 5) the study of changes in the emotional-volitional sphere of the child.

The examination begins with an examination of the articulation apparatus. A speech therapist classifies the type of cleft, finds out at what age the lip and palate plastic surgeries were performed, and then describes in detail the state of all organs of articulation.

With a cleft of the upper lip, its mobility, the severity of cicatricial changes, and the condition of the bridle are noted.

Examining the palate before surgery, attention is paid to the size of the defect and the mobility of the segments of the soft palate. After the operation, describe the shape of the arch, scars, their degree of severity, the length and mobility of the palatine curtain.

It is known that, normally at rest, the small uvula is 7 + 0.1 mm from the posterior wall of the pharynx and hangs from the plane of the chewing surfaces of the upper teeth by 0.9 ± ± 0.3 mm. If the distance from the edge of the small uvula to the posterior wall of the pharynx can be measured quite accurately with a small, dispensed ruler with non-sharp edges, then the height of the uvula is very difficult to determine and most often it is necessary to do this by eye.

The mobility of the palatine curtain is easy to observe with a smooth, drawn-out pronunciation of a vowel sound a, when the baby's mouth is wide open.

At the same time, the speech therapist has the ability to visually assess the density of the palatine-pharyngeal occlusion and the activity of the lateral pharyngeal walls during phonation.

With the complete immobility of the soft palate, it is necessary to try to induce the pharyngeal reflex by touching the back and side walls of the pharynx with a spatula. The involuntary jerk of the palatine curtain upward observed in this case, firstly, shows that the mobility of the soft palate is in principle possible and should be developed, and secondly, it demonstrates the approximate level of closure that can be achieved in the future.

At the same time, it is possible to assess the pharyngeal reflex, which, depending on the severity, is characterized as preserved, increased or decreased. It is known that attenuation of the reaction of the pharyngeal muscles to a stimulus can begin at 5 and end as early as 7 years. A correct assessment of the activity of the pharyngeal muscles is especially important for children who have to wear a functional pharyngeal obturator.

The tongue must be described in detail, dwelling on the features of its position in the oral cavity, the state of the root and tip. They note his excessive tension or lethargy, limitation of mobility. To do this, spread a wide tongue on the lower lip, pull it out with a "sting", raise, lower, drive right and left, lick lips, etc. All movements are performed in imitation, and then according to the instructions of a speech therapist in front of a mirror and without it.

Changes in the dentition are recorded only if they affect speech, and changes in the bite are marked without fail, just as in the presence of an orthodontic apparatus, it is necessary to record the purpose of its application, the type, density of fixation and decide whether it will interfere with articulation exercises and sound pronunciation.

The features of the palatine arches and the opening of the oral cavity are noted only in the presence of any deviations. At the end of the inspection, check the directed air jet. To do this, the child is offered to spit, blow on the cotton wool with his lips, and then blow with his tongue sticking out. All this is done with the open and clamped wings of the nose.

The level of speech development is found out by checking the pronunciation, vocabulary of speech, its grammatical structure, as well as phonemic hearing.

Analyzing the features of sound pronunciation, the speech therapist checks the sound and articulation of all phonemes of the Russian language, first by imitation, and then by independently pronouncing isolated sounds, words and sentences. The child first repeats individual phonemes after the speech therapist, and then the words - simple and with a confluence of consonants, and literate children read them. Preschoolers call subject pictures, and a conversation is conducted with them according to the plot pictures.

It should be remembered that a child can pronounce sounds in different ways when repeating after a speech therapist, reading and talking on an assignment and in spontaneous speech, and therefore it is necessary to check all these types of speech activity. The peculiarities of the pronunciation of spontaneous speech are most clearly manifested when answering simple everyday questions, when the child does not need to think about the content of the answer and he can speak quickly, for example: “What is your name? Where do you live? Where did you and your mom come? Do you go to kindergarten? Which group? What are the names of your teachers? "

Having established the defective sound, it is necessary to mark in the map in what kind of speech activity it suffers and what is the nature of the violation: distortion, replacement, absence, soundless pronunciation, concomitant closure. When the sound is distorted, the articulation defect is accurately indicated, for example: lateral sibilant sigmatism, pharyngeal (or pharyngeal) sibilant and sibilant sigmatism, deafening of explosive phonemes, lip-labial pronunciation n, n ", b, b" etc.

All material used in the examination should correspond to the age and development of the child, since, repeating unfamiliar words or trying to name or describe new objects or phenomena, he may demonstrate a worse sound pronunciation than is usually characteristic of him.

After examining the pronunciation, the general impression of spontaneous speech is indicated: legible, illegible, blurred, with excessive nasal resonance. In this case, an objective assessment of intelligibility according to the tables of NB Pokrovsky is possible. However, such a survey takes a lot of time, without significantly affecting the organization and results of correctional and pedagogical work.

To determine the severity of nasal resonance in the literature, a description of a large number of various devices is given. Their basic principle of operation is to measure the volume of air that enters the nasal cavity during speech. By the ratio of this volume to the total volume of exhaled air, the severity of open nasalization is judged. However, in fact, such devices indicate not the severity of nasal resonance, but the compensation of the opharyngeal seal.

The existing relationship between the volume of air leaking into the nose and the degree of nasalization is not direct, since various compensatory mechanisms are involved in speech. In addition, air and sound flows obey different physical laws, which also does not allow their data to be correlated. Foreign bodies introduced into the nose during such studies disrupt the physiological conditions of speech formation in a child.

The use of spectral analysis makes it possible to maintain normal conditions for speech formation, however, tape recording requires special conditions and a spectrograph.

All these features of objective assessment methods make it difficult to apply them in practical institutions. In the special literature, there are numerous data indicating that audit assessments coincide with the results of spectral analysis, and the most stringent judges are speech therapists. In practice, it is customary to subdivide the nasal resonance of the voice with open rhinophonia into mild and pronounced.

When examining phonemic hearing, the child repeats after the speech therapist, whose face is hidden by the screen, isolated sounds, syllables and words that differ only in one phoneme (such as: Forest- bream, tata- cotton wool). If a child replaces whole groups of sounds with one, then instead of repeating words, it is better for him to select object pictures corresponding to the words.

The possibilities of sound-letter analysis are checked for those who have literacy. Children determine the order of sounds in words, compose them from a split alphabet, select pictures for a given sound and letter. When selecting words with a specific phoneme or when finding a letter in a word, words are first analyzed in which the desired phoneme (or its letter designation) is the first, then the last, and only then in the middle. For such work, words are selected only with solid variants of consonants.

When replacing entire groups of sounds with any one (for example, with pharyngeal sibilant and sibilant sigmatism), literate children can also select a card with a written syllable. This allows you to check the perception of each consonant sound from these groups.

In conclusion, it is necessary to find out how the child perceives his own pronunciation: whether he differentiates his shortcomings by ear or knows about them only from the words of others.

Changes in the emotional-volitional sphere cannot be detected immediately. They learn about them after observing the child for a long time. But already at the first visit, it should be noted how the child comes into contact with strangers. Stiffness, the desire to answer questions with gestures and facial expressions show that the child is aware of the speech disorder and is ashamed of it.

In the future, in conversations with parents, it is necessary to find out how they relate to the child in the family, whether there is hyper or hypo-care, whether the child has friends, what age they are, whether he loves the company of children, how he relates to kindergarten, whether he is teased in the yard , in kindergarten, at school, how other children treat him, is he active in the classroom, does he like to visit, go to a health camp.

It is very important to know whether the child is interested in his disability and in what way, how he reacts to the comments of others regarding speech and whether he has a desire to correct the deficiency.

In the future, all these data will indicate the direction of psychotherapeutic conversations, help develop a conscious attitude to classes, create a correct attitude towards the child and his behavioral characteristics in the microenvironment. Of course, the listed questions do not exhaust the whole diversity of the personality. Only long-term observation makes it possible to find out the mass of individual characteristics of the child, the knowledge of which helps to properly educate the personality and avoid the development of unwanted pathocharacterological reactions to the defect.

All survey data are recorded in the outpatient card.

Numerous variants of the ratios and manifestations of pathological symptoms give a varied clinic of rhinolalia, despite the presence of common basic pathological components. This forces us to emphasize the individual approach to work. Speech therapy classes with children suffering from congenital cleft palates should be conducted only individually. Group classes are not suitable for several reasons.

First of all, differences in changes in functions in depth and volume require the selection of certain targeted training. Even at one stage of the class, children of the same age may need different recommendations. Since each child's organism has individual endurance, the number of exercises, as well as their complex, is selected individually.

It is known that fuzzy, incorrect repetition leads to the consolidation of pathological skills. Considering that often only the visual analyzer serves as a support for control in rhinolalia, and therefore the possibilities of correct repetitions are limited, not a single movement, sound, word in the classroom should be left without the attention of a speech therapist. At the same time, the child needs constant reinforcement with verbal instructions. In the group, it is often not possible to notice deviations in small subtle movements and the sound of phonemes.

In addition, the inability to correctly complete a task that is easily given to others often generates negativism in kids and even a complete refusal to study. The seniors, on the other hand, awaken a feeling of inferiority, they lose faith in their strength.

The excitement that usually occurs in a group during blowing exercises distracts children from focused activities.

One lesson lasts an average of 30 minutes. In the lesson, correctional and educational work is carried out in all areas. Only for breathing exercises do children go to the physiotherapy room.

During the reception, an adult must be present in the office, who will train the child at home. He must have a special notebook and write down all instructions and tasks in detail in it. The speech therapist specifies exactly how many times each exercise should be repeated at home. Parents need to work with their child several times a day for no more than 10-15 minutes at a time.

The true calendar of our ancestors

In the south, the Tartars bordered on their southern neighbors - the Arim, the inhabitants of Arimia, as Ancient China was called at that time. Several thousand years ago, the Arim took advantage of the weakening of the metropolis, and a heavy war ensued. As a result, the victory over Ancient China was won. 7521 years ago . September 22 - Day of the Creation of the World (from S.M.) - conclusion of a peace treaty. The victory was so significant and difficult that our ancestors chose this date as a new starting point for their history.

So, Russian history has more
seven and a half thousand years new
era (!), which came after the victory in a difficult war with Ancient China.

The symbol of this victory was Russian warrior piercing a serpent with a spear, now known more as St. George the Victorious. The Serpent identified the Dragon, and Ancient China in the past was called not only Arimia, but also the land of the Great Dragon... The figurative name of the country of the Great Dragon has been preserved for China to this day.

This event turned into Russian folk tales, in which Ivan Tsarevich defeats the Serpent Gorynych. No wonder each of the Russian fairy tales ends with a line: "The fairy tale is a lie, but there is a hint in it, a lesson to a good fellow."

... When the Romanovs were seated on the throne in the Moscow principality, a systematic distortion of the history of the Slavs and other peoples! Russian history was pretty much "rewritten", the ancient libraries that preserved ORIGINALS texts carefully BURNED. Peter I Romanovich in the summer of 7208 from S.M. introduced the Christian calendar on the lands of Muscovy. Summer 7208 from S.M. by the decree of Peter it turned in 1700 A.D.

In the years 1749-1750 Lomonosov opposed the then new version of Russian history, created before his eyes by Miller and Bayer. However, practically all THIS (and not rewritten later) works that Lomonosov intended to publish, were confiscated and “ disappeared»Without (c) trace.

The main methods of distorting history have always been: substitution of true artifacts copies or the presentation of true artifacts (maps of Tartary, monuments with a different chronology, etc.) as mythological... What was all this done for? ..

But without studying our true past, we will not be able to determine WHAT steps need to be taken in order to avoid mistakes in the future and make it the way we want it. It is necessary to restore logical chains and analyze events of the past and present in the context - "cause - fact - effect"... Then thinking will become logical and flexible, and not event-driven and linear.

"People who do not know their Past have no Future"

Read more about distorting history - on the sites levashov.info and kramola.info