Evaluation and Treatment: using low-tech and no tech procedures

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1 Evaluation and Treatment: using low-tech and no tech procedures

2 6. Perceptual Evaluation When, What, How, and Why When the evaluation should be done for the most reliable results and maximum benefit for the patient What to assess How to do a perceptual evaluation using simple low-tech and no-tech procedures Why the speech evaluation is needed to make appropriate management decisions

3 Evaluation of Velopharyngeal Function Need connected speech Need cooperation for stimulablity testing and instrumental assessment Need to be big enough so airway is not a concern Usually around the age of 3

4 Caveat: Don t wait too long! Early intervention is very important! Critical period of brain development Dependent on afferent and efferent sensory stimulation Need to intervene during critical period

5 Caveat: Don t wait too long! Consequences of waiting too long Correction will take longer Prognosis is negatively affected Can affect social and emotional development

6 What to Evaluate Articulation Nasal emission Weak consonants Short utterance length Resonance Voice (Phonation)

7 Articulation Placement errors Phonological errors Developmental errors Obligatory versus compensatory errors

8 Obligatory Errors Hypernasality Nasalization of oral phonemes (m/b, n/d, ng/g) Nasal emission Weak or omitted consonants Short utterance length

9 Compensatory Errors Glottal stops Pharyngeal fricatives Pharyngeal plosives Note: These can also be due to mislearning in the absence of VPI

10 Nasal Emission Need to determine the type: Nasal emission (large gap) Nasal rustle (small gap) Due to abnormal structure Misarticulation which causes phonemespecific nasal air emission

11 Nasal Rustle Can be structural or functional Structural Defect Caused by small defect Occurs inconsistently, but on all pressure sounds, including /p/ and /t/ Functional Error Caused by misarticulation Occurs consistently, but only on certain sibilants, particularly s/z

12 Resonance Need to determine the type: normal resonance hypernasality hyponasality cul de sac resonance mixed resonance

13 Resonance Severity Rating scales: Seven point scale Normal, mild, moderate, severe Present or absent

14 Phonation Evaluate for signs of dysphonia: Hoarseness Breathiness Low or high pitch

15 Speech Samples Single word articulation test NOT good!!!

16 Speech Samples Prolongation of sounds Repetition of syllables Counting Repetition of sentences with pressure-sensitive consonants Connected speech

17 Repetition of Single Sounds Oral sound to test hypernasality: vowels, particularly /ah/ and /eee/ Oral sounds to test nasal emission: prolonged /s/ Nasal sound to test hyponasality: prolonged /m/

18 Repetition of Syllables To test hypernasality or nasal emission, use oral consonants with high and low vowels: pa, pa, pa, pa ta, ta, ta, ta ka, ka, ka, ka sa, sa, sa, sa pi, pi, pi, pi ti, ti, ti, ti ki, ki, ki, ki si, si, si, si sha, sha, sha, sha shi, shi, shi, shi

19 Repetition of Syllables To test hyponasality, use nasal sounds with high and low vowels: ma, ma, ma, ma na, na, na, na mi, mi, mi, mi ni, ni, ni, ni

20 Counting To test nasal emission: Count from 60 to 70 Repeat 60 or 66 over and over 66 = SIKSTY SIKS Good combination of plosives and fricatives in blends

21 Counting To test hyponasality: Count from 90 to 99 Repeat 99 over and over

22 Repetition of Sentences p/b: Popeye plays baseball. t/d: Take Teddy to town. Do it for Daddy. k/g: Give Kate the cake. Go get the wagon. f/v: Fred has five fish. Drive the van. s/z: I see the sun in the sky. sh: She went shopping. ch: I ride a choo choo train. j: John told a joke to Jim. l: Look at the lady. r: Run down the road. I have a red fire truck. th: Thank you for the toothbrush. Blends: splash, sprinkle, street

23 Stimulability and Consistency Does change in placement change VP function? Stimulability is a good prognostic indicator for improvement or correction with therapy

24 Either/Or Questions What do you like best? Puppy dogs or kitty cats? Baby dolls or teddy bears? Cup cakes or cookies? Baseball or basketball? Dancing or singing?

25 Low-Tech/ No-Tech Procedures Use same type of speech samples»see»feel»hear

26 See: Cold mirror

27 See: Air Paddle

28 See: See-Scape

29 Feel: Feel Sides of Nose

30 Hear: Nose Pinch (Cul de Sac) Test

31 Hear: Stethoscope

32 Hear: Straw

33 Hear: Listening Tube

34 Prediction of Size of Gap based on perceptual features Hypernasality, inaudible nasal emission, weak consonants, short utterance length Hypernasality, audible nasal emission, weak consonants, short utterance length Nasal emission Nasal rustle (turbulence)

35 7. Intra-Oral Evaluation

36 Intra-Oral Evaluation Can evaluate oral structures and oral function Cannot evaluate velopharyngeal structure or VP function View is well below area of closure

37 Tools for an Intra-Oral Exam Gloves Light Dental mirror Tongue blades (preferably the flavored kind) Antimicrobial hand rinse

38 Intra-Oral Evaluation Dentition and occlusion Oral cavity size for tongue movement Presence of a fistula Signs of a submucous cleft Position of the uvula during phonation Size of the tonsils Signs of oral-motor dysfunction Signs of upper airway obstruction

39 Dental and Occlusal Exam

40 Fistula Effect depends on location and size

41 Palatal (Oronasal) Fistula

42 Palatal Fistula

43 Fistula and Tongue Flap

44 Fistula and Tongue Flap

45 Oronasal Fistula vs. VPD Occlude the fistula with gum or fruit roll up OR Compare the degree of nasal air emission for anterior sounds and posterior sounds

46 Intra-Oral Evaluation Need to see to the tip of the uvula Avoid using a tongue blade

47 Say aaaah as in bat and protrude the tongue

48 Aaaah

49 Normal Velum Color is pinkish and consistent White line down the middle (median raphe) Velar dimple about 80% back during phonation Uni-uvula

50 What s this?

51 What s this?

52 Stigmata of a Submucous Cleft Some or all of the following: Bifid or hypoplastic uvula Zona pellucida (bluish area) Abnormal insertion of muscles causing a V- shape with phonation Notch in the posterior border of the hard palate

53 Submucous Cleft

54 Submucous Cleft

55 Submucous Cleft

56 Video: Submucous Cleft

57 What s this?

58 Torus Palatinus

59 Tonsils Judge the size Look for asymmetry May affect position of the uvula

60 Uvula Evaluation position of the uvula during rest and phonation Look for deviation or pointing to one side

61 Evidence of Upper Airway Obstruction Open mouth posture Suborbital shiners (black eyes) Strident breathing Snoring and history of restless sleeping

62 Signs of Oral-Motor Dysfunction Drooling History of feeding problems Inconsistent artic errors

63 8. Instrumental Evaluation: How can we measure resonance and VP function?

64 Nasometry Computer-based Analyzes acoustic energy from oral and nasal cavities Nasalance: ratio of nasal/total energy Can compare score to normative data

65 Video: SNAP Test-Sibilants Passage Normal Speech

66 Video: SNAP Test- Suzy Passage Nasal Rustle

67 Pressure-Flow Technique Aerodynamic instrumentation Measures air pressure and airflow during production of a small speech segment Gives estimate velopharyngeal orifice size

68 Pressure-Flow Technique Catheters: One in a nostril and one in mouth Connected to a pressure transducer Flow Tube: One in the other nostril Connected to a heated pneumotachograph Reproduced with permission from David Zajac, PhD

69 Videofluoroscopy Multi-view radiographic assessment (lateral, frontal, base) Can see all VP structures Can evaluate function during speech Studies are interpreted by both a radiologist and a speech pathologist

70 Videofluoroscopy

71 Videofluoroscopy

72 Lateral View

73 Frontal (Anterior-Posterior) View

74 Base View

75 Nasopharyngoscopy Allows direct, up close observation of VP structures and function during speech

76 Nasopharyngoscopy vs. Videofluoroscopy Done without radiation Better tolerated by even young patients (barium is noxious!) Can see entire port in one view Much better resolution No false negatives (head rotation) Can see even small gaps

77 Nasopharyngoscopy Equipment

78 Prior to Exam

79 Nasal Spray Afrin and Pontocaine thru nose spray

80 Does it hurt when you pick your nose?

81 Nasopharyngoscopy Endoscope passed thru middle meatus, thru choanal orifice to VP port

82 Nasopharyngoscopy Nasal surface of velum and VP function observed and recorded during speech

83 Video: Fistula and VPI

84 Occult Submucous Cleft

85 Small Circular Gap in Midline

86 Small Lateral Gap

87 Bowtie Closure

88 Bowtie Closure

89 Narrow Coronal Gap

90 Coronal Gap with Touch Closure in Midline

91 Moderate Opening in Midline

92 Large Opening

93 Nasopharyngoscopy Scope can be passed by either a physician or speech pathologist Speech sample should be determined by speech pathologist Interpretation requires the expertise of a speech pathologist

94 Determine Probable Cause Velopharyngeal insufficiency VPI) surgery (speech therapy postop) Velopharyngeal incompetence (VPI) surgery (speech therapy postop) prosthetics- palatal lift speech therapy Velopharyngeal mislearning speech therapy

95 9. Treatment Surgery Prosthetics Speech therapy

96 Surgical Management Procedure chosen depends on: Size of gap Cause of gap Location, location, location!

97 Surgery for VPI Pharyngeal augmentation Furlow Z plasty Pharyngeal flap Sphincter pharyngoplasty Note: These do not always work the first time. May need revision or even re-do.

98 Pharyngeal Augmentation Injection of a substance in the posterior pharyngeal wall Can use fat, collagen (Demalogen, Simetra) or Radiesse (hydroxyl apetit) Good for small, localized gaps or irregularities of the posterior pharyngeal wall

99 Furlow Z Plasty Often used as a primary palate repair Can be used as a secondary repair to lengthen velum Appropriate for narrow, coronal gaps

100 Pharyngeal Flap

101 Pharyngeal Flap View from nasopharyngoscopy before and after flap

102 Pharyngeal Flap

103 Pharyngeal Flap

104 Pharyngeal Flap (Patient s) left lateral port

105 Pharyngeal Flap (Patient s) right lateral port

106 Pharyngeal Flaps Both are too low

107 Video: Pharyngeal Flap

108 Video: Pharyngeal Flap

109 Sphincter Pharyngoplasty

110 Sphincter Pharyngoplasty Too narrow and too low

111 Prosthetic Devices Palatal lift Palatal obturator Speech bulb

112 Palatal Lift To raise the velum when velar mobility is poor (velopharyngeal incompetence) Commonly used with dysarthria

113 Palatal Obturator To close or occlude an open cleft, palatal defect or fistula

114 Speech Bulb (Speech Aid) To occlude nasopharynx when the velum is short (velopharyngeal insufficiency) Can be combined with an obturator

115 Speech Bulb

116 Palatal Obturator with Bulb

117 Limitations of Prosthetic Devices Require insertion and removal Have to redo periodically due to growth Can be lost or damaged May be very uncomfortable Compliance is often poor Don t permanently correct the problem Many centers use only if surgery is not possible

118 Speech Therapy CANNOT change abnormal structure or correct VPI Can change abnormal function as a result of VPI or velopharyngeal mislearning

119 Indications for Speech Therapy Compensatory productions due to VPI (before and after surgery) Misarticulations due to mislearning Oral-motor dysfunction (dysarthria or apraxia) Following surgical correction- Changing structure does not change function.

120 Speech Therapy for Hypernasality or Nasal Emission Before Surgery While waiting for physical management- can use nose plugging technique to work on articulation

121 Speech Therapy for Hypernasality or Nasal Emission After Surgery/Normal Structures Use auditory feedback Nasal tube works, but SLP or parent can t hear what child hears

122 Auditory Feedback: Oral & Nasal Listener* * Super Duper Publications- 2007

123 Therapy for VP Mislearning glottal stops ng/l substitution nasalized vowels nasalized /r/ pharyngeal plosives mid dorsum palatal stop/ lateral lisp pharyngeal fricatives/ posterior nasal fricatives

124 A final word about therapy Do not use blowing or sucking exercises!!! Do not use oral-motor exercises!!! They have no theoretical basis in most cases They don t work!

125 Goal of Treatment Normal speech and resonance Normal speech with no evidence of nasality Acceptable speech is not acceptable

126 10. Referrals Check Around... This is a specialty area for all disciplines (ENT, surgery and speech path) Refer to a craniofacial team Check with American Cleft Palate- Craniofacial Association (ACPA) for professionals with experience in this area (

127 Team Approach: Cincinnati Craniofacial Center

128 For more information... Kummer, AW. Cleft Palate and Craniofacial Anomalies: Effects on Speech and Resonance, 2 nd Edition, Thomson Delmar Learning, 2008.

Resonance Disorders and Velopharyngeal Dysfunction: Evaluation and Treatment

Resonance Disorders and Velopharyngeal Dysfunction: Evaluation and Treatment Ann W. Kummer, PhD, CCC-SLP Cincinnati Children s Hospital Medical Center Resonance Disorders and Velopharyngeal Dysfunction