When to refer to an Otolaryngologist (ENT) as an SLP

What is an ENT?

ENT doctors can treat conditions that affect head and neck systems specifically with the ears, nose, and throat. They can treat ear problems such as hearing loss and tinnitus, they treat issues with the nose such as allergies and sinusitis, as well as the throat including difficulty swallowing and voice changes.

As a speech language pathologist we often evaluate a client who may sound hypernasal or hyponasal speech, but are unsure of what to do next. An ENT referral can help rule out any ear, nose, or throat disease/conditions that can be affecting a child’s speech.

Red Flags that would warrant an ENT referral:

• Chronic mouth breathing
• Chronic ear infections
• Chronic respiratory infections
• Persistent gravel vocal quality, strained vocal quality
• History of vocal abuse
• Hypernasal and/or hyponasal vocal quality
• Symptoms of sleep-disordered breathing
• Persistent colds

How do enlarged tonsils impact speech?

• Enlarged tonsils and/or adenoids often result in an occluded airway that forces a child to mouth breathe versus nasal breathe 
• Studies show that mouth breathing is correlated with significant changes to the face and mouth, including a high and narrow palate, low oral rest tongue posture and a narrowing airway

Enlarged tonsils/adenoids can change the structure of a child’s mouth:

• Large tonsils and/or adenoids can push the tongue forward and out of the mouth because there is not enough room to fit the tongue inside
• They may also change how the voice sounds (e.g., not enough air coming out).  Your child may sound like they are sick with a blocked nose
• Enlarged tonsils can also lead to sleep disturbances such as snoring or obstructing the airway during sleep

Hyponasality:

• Hyponasal speech is when your child sounds like they have a cold. This happens when insufficient air leaves the mouth or nose during speech production.
• In more severe cases, hyponasality co-occurs with denasalization of nasal consonants (/m/, /n/, and /ŋ/), making them sound more oral in quality (e.g., /b/ for /m/, /d/ for /n/, and /ɡ/ for /ŋ/)
• Enlarged adenoids are almost always the cause of hyponasal speech, because the inflamed tissues block the air passage in the nose. This also leads the child to mouth breathe
• Common causes of hyponasality are: adenoids, common cold, nasal allergy
• Treatment: surgical management for hyponasality involves procedures to correct anatomical sources of obstruction
  • Procedures include: tonsillectomy/adenoidectomy, removal of nasal polyps, surgery to correct deviated septum, surgical removal of tissue or bone of the nasal passage, surgical reconstruction to enlarge stenotic nares.

Hypernasality:

• Hypernasal speech on the other hand, occurs when too much air leaves the nose while the child is talking.
• A child can have trouble pronouncing the letters “b”, “k”, “s” or vowels like ‘a’ or ‘e.’ This often happens in children with cleft palate issues or poor muscle control like in cerebral palsy
• The ENT might also perform X-rays and a study of the nasal airflow called a Nasometry test
• Common causes of hypernasality are: post adenoidectomy, velopharyngeal port sufficiency (VPI), Cleft or soft palate
• Treatment: Surgical management is the most common treatment for hypernasal speech due to velopharyngeal insufficiency (structural) and may also be used to treat oronasal fistulas that are symptomatic for speech.
  • Procedures include: pharyngeal flap and pharyngeal wall augmentation

What should a speech therapist look for:

• When assessing a child’s speech, a speech pathologist will look at how a child’s oral structures are developing. If they notice any of the following things, this may warrant a referral to an ENT:
  • Nasal quality of the voice (either too much air or not enough air coming out when talking)
  • Mouth breathing
  • Tongue thrust
• Obtaining speech sample to look for:
  • signs and symptoms of resonance disorder, including sounds affected, consistency of symptoms, and severity
  • presence of nasal emission (obligatory or learned)
  • presence and type of articulation errors