RDH questions re enlarged tonsils, timing for therapy, speech considerations

Hi Sandra, Question, I had a kid yesterday, 4 years old, mouth open posture with interdental tongue posture.  Tonsils very enlarged (not kissing) and sees ENT regularly. Because they are not getting infected at all he is waiting to see if normal child growth will rectify the problem but advises mum that she has 60 % airway.  I am no sp therapist (hence I need your help)  but her speech was unintelligible,  BAD ! I had a 3 year old last wk for finger sucking that I could understand far better. This patient was rec through another parent I have    so $ not issue and all kind so tests etc have been done re her development and they cannot find anything, BUT she was not able to start school at 3 as she was not ready and the session demonstrated yesterday that she is not a candidate for therapy with me at this time (although she sure needs it)  she would not allow me to do lip strength and spots – no way.  Not able to focus, crying etc. So told mum to forget it and mum could see it too.   It is still bugging me though.  Could her speech be sooooooo poor due to the 60 % airway or is there some delayed development issue that no one knows about??????   And although I am unable to do OM therapy would she benefit from speech therapy at this time?  Or is it a waste of time referring for speech at this time until tongue posture sorted HELP!    I feel I want to help but not sure how I can!!!! Her Son (8 yrs) came after – lovely kid –  open mouth posture, low tongue posture with short frenum – 59 mmm ROM but unable to get any measurement with suction as not able to suction tongue so visibly could see that the tongue even touching the top of mouth and trying to open was just a mere finger width. also 6mm overjet (and her dentist told her not to worry with ortho LOL!)      she is promptly going to see Ortho asap! And I have rec that the frenum be clipped. He  had kissing tonsils as a kid and constant infections and had them removed at 2 ½ years .   Anyway he will be a great candidate for therapy. Next question…… mum says that if removing the daughters tonsils will improve her speech she will do it, but I do not feel qualified to answer that question and make such a recommendation especially as she is seeing the ENT?  (My referring mum of this mum also sees this ENT and just happened to drop my brochure to him!!!!  So at least I have an ENT now who at least knows I am here!!! – and word of mouth is such a great way to get referrals. I am noticing that if kids even have the slightest restriction with lingual frenum I am referring for frenectomy because I feel very strongly that it will tremendously help the kid in soooo many ways for the rest of his life.  What are your views….. am I overreacting ?  Or do you refer a lot for the lingual frenectomies.  ( this is my second kid I am sending – had a really bad one the other day and he does procedure in a couple of weeks)  I just think it is such a relatively painfree quick procedure that it has to be of benefit.  What I am really saying is that sometimes we have to use judgment as measurements are not always possible as the kid just cannot get his tongue up and suction is that ok to make recommendation for referral on that basis ?  Look forward to a response…. T  

Since some speech problems are related directly to orofacial myology issues and some are not, we’d need to analyze the type of speech problems she is having.  If her tongue is low and forward and she makes poor s and z sounds, perhaps t, d, n and L sounds…that is very likely to be an orofacial myology related problem.  If, additionally, she has open lips posture, that is something that can be addressed even while waiting for more maturity for further treatment.  (but do the Quiet Time TTS exercises  only if she CAN breathe easily through the nose; otherwise, limit yourself to  the other types of lip exercises described in the Myo Manual).  Now, if she cannot, for example, make the “blend” sounds, such as omitting the S or the T in such words as    STOP (says “top” or “sop”), or SPIN (“pin” or “bin”, etc.)…that is not usually a myo issue and should be addressed.  Does she also sound hyponasal (somewhat “clogged” voice quality?) Whether there is a strong history of ear infections should be noted since that sometimes contributes to unintelligible speech.  Are her vowel sounds “off” as well?  You have to pick apart the speech to get a better idea.  Can she say individual words well and then loses clarity within a sentence or during regular conversation?  As far as seeing underneath the tongue and getting a view of the elevation capacity, you have to have them open the mouth fully; then you tap on the spot (even the upper centrals if necessary, just to direct their tongue upward so you can get a good look at the frenum.  Stabilizing the mandible with a 2 or 3Way Mouth Prop or other item will help here.  Regarding referral to an ENT for T & A evaluation, it depends upon which symptoms and how severe they are since surgery is not my first choice about most things.  But if a child’s life is being affected  (even if they don’t realize it because they have adjusted to their own “misery”), then it must be considered. If the tonsils subside in size, it is usually around puberty; thus, depending upon how much they are affecting her, she might have a long wait for relief.  If they are only inconsistently enlarged, then they are merely “doing their job”…but if they are chronically affecting her respiration, lingual resting posture, speech, etc., then that is something to consider. If she exhibits any of the symptoms other than the orofacial myology ones and if you feel that her language or receptive skills/comprehension skills might be below expectation, then it would be prudent to have a speech pathologist see her; however, give the SLP your input about myo findings because the SLP who is untrained in myo might erroneously treat the child for the lisp, etc. that should wait for myo treatment first.  In your class with me, did I go into what you should do if the child cannot suction?  I have found that you can use TTS (tongue to spot) measurement in place of the MOWS, and subtract approximately 2-5 mm and that is usually what the MOWS “would” have been had you been able to measure the suction opening.  Do you understand what I mean here?  Hopefully, the quick QTT measurement using the TTS as described above will help you make decisions.  Remember, however, that there is much more to consider in those cases where the QTT result is borderline, etc.  Look at the attachment on the tongue itself; look at the attachment on the floor of the mouth (or is it right under the lower alveolar ridge, or even “on” the low alv ridge); is it flexible, taut, short, etc.  Consider the entire frenum and attachments, locations, and limitations of lingual excursion; speech? diastema? labially tipped dentition?  etc.  Then you have to pretend the kiddo’s your own and then have the discussion with the parent.  Now, when there is no question in my mind and the frenum is clearly attached anteriorly then it’s a no-brainer.  Or if it is short AND poorly located, it’s easier to determine.  But some are short, yet far down on the tongue AND well back on the mouth floor and they may be fabulous!  So function becomes important to consider in such a case, not just “length”!   With regard to this child’s “readiness” to be seen for myo or speech therapy, some of what you mentioned puts that into question.  Most SLPs can work with children, even those who are noncompliant, so it might be very prudent to refer her to a speech pathologist and see what the findings are, if the SLP recommends other types of testing, etc.  Let me know if this is helpful or if you wish to have some further input.