Cleft Palate &/or Velopharyngeal Inadequacy Assessment or How to Determine Nose vs. Mouth Sounds

Cleft Palate &/or Velopharyngeal Inadequacy Assessment

or How to Determine Nose vs. Mouth Sounds

KSHA Conference Presentation

10/01/2010

Sally Helton, MS, CCC-SLPSpeech/Language Pathologist

Children’s Mercy Hospitals & ClinicsKansas City, Missouri

Hearing & Speech Department913-696-5756

Introduction

• Educational Background• # Years at CMHC• # Years CMHC Cleft Palate/Craniofacial Team• # Years CMHC FFVN Team• # Years Member ACPA• Primary Job Function• Other Job Functions

Intent of Presentation

• To provide information regarding diagnostic assessment for communication disorders due to cleft lip &/or palate &/or velopharyngeal inadequacy

• To provide information regarding other issues that impact cleft lip &/or palate &/or velopharyngeal inadequacy

• To provide information regarding importance of team approach to treatment

• To provide referral criteria for more advanced assessment, perceptual &/or instrumental

Basic Terminology

Cleft Lip

• A cleft of the lip which may be:

-complete or incomplete

-unilateral or bilateral

-extend to the nostril

-extend to the alveolus

Cleft Palate

• A cleft of the palate which may be:

-complete or incomplete

-unilateral or bilateral

Cleft Palate cont’d.

-submucous

-overt: observe one or more of:

-bifid uvula

-zona pellucida

-muscular diastasis

-notch in posterior border of hard

palate


• Submucous cont’d.

-occult (hidden)


• Variations

• Incidence

• Other Clefts

• Classification Systems

ACPA

• American Cleft Palate-Craniofacial Association

22q deletion

• Deletion of genetic material from chromosome 22

• Other names: 22q11.2 deletion

Shprintzen’s Syndrome

Velo-Cardio-Facial Syndrome

22q deletion cont’d.

• Other manifestations

• Organ systems affects

• Variable expression

• Incidence

• Significance in regard to education

Flexible Fiberoptic Video Nasopharyngoscopy (FFVN)

• Invasive procedure used to evaluate the structure & function of the velopharyngeal mechanism during speech.

Velopharyngeal Mechanism

• Velo: velum/soft palate

• Pharyngeal: lateral & posterior pharyngeal walls

• Pharynx: part of throat between esophagus & nasal cavity

Velopharyngeal Port

• Port or gateway formed by action of the pharynx & velum to control the flow of air and sound through the mouth & nasal passages

Velopharyngeal Valve

• Valve which closes & opens velopharyngeal port between nasopharynx & oropharynx

• Formed by velum & aided by posterior & lateral pharyngeal walls

• Nasopharynx: part of pharynx above soft palate & just behind nasal cavity

• Oropharynx: part of pharynx below soft palate at the level of the oral cavity

Velopharyngeal Closure

• Closing of nasal cavity from the oral cavity

• Accomplished by using velum & pharynx & possibly adenoid tissue

• Directs airflow through mouth instead of the nose

Velopharyngeal Inadequacy (VPI/A)

• Generic term

• Refers to any abnormal velopharyngeal function

• Diagnosed perceptually (by listening)

Velopharyngeal Inadequacy cont’d.

• 3 basic subtypes:

-velopharyngeal insufficiency (VPI/S)

-velopharyngeal incompetency (VPI/C)

-velopharyngeal mislearning

Subtypes CANNOT be distinguished perceptually.

Subtypes are not mutually exclusive.

Velopharyngeal Insufficiency (VPI/S)

• Structural defect of the palate &/or pharyngeal area

Velopharyngeal Incompetency (VPI/C)

• Neurogenic impairment

• Movement disorder/motor planning

• Not structural

Velopharyngeal Mislearning

• Functional disorder

• Faulty learning of articulation patterns

• Sound (phone) specific nasal air emission (s)

Relationship of VPI/A Types

Learning(articulation disorder)

VP Mislearning

Physiology(movement)

VP IncompetencyVPI/C

Anatomy(structure)

VP Insufficiency(VPI/S)

Relationship of VPI/A Types cont’d.

• Significance of relationship:

if types are not mutually exclusive, treatment will need to target all types presented by the patient


• Significance of relationship:

diagnostic assessment needs to determine types of VPI/A the patient presents

diagnostic assessment should include perceptual evaluation & possible instrumental/more invasive evaluation such as FFVN


• Instrumental diagnostic assessment with FFVN needs to be a VALID study

• Use or attempted use of high pressure consonants is REQUIRED for a VALID FFVN study

• If high pressure consonants are not being used/attempted, speech therapy should occur first.

Areas of Assessment

• History

• Articulation

• Resonance

• Nasal Air Emissions (NAE)

• Velopharyngeal Adequacy

• Language

• Voice

• Fluency

• Oral Mechanism/Oral Peripheral Examination

Tools Needed for Assessment

• Tissues

• Gloves

• Flashlight

• Mirror

• Reinforcers/Toys

• Articulation test & score form

• Language test & score form

• Resonance/NAE protocol form (stimuli)

• Tape recorder (optional)

Tools Needed for Assessment cont’d.

• CMHC Protocol

• ACPA Universal Parameters for Assessment

(The Cleft Palate-Craniofacial Journal, January 2008, Volume 45, Number 1, Henningsson et.al., pg. 1-17)

Assessment-HistoryAreas to Consider

• Cleft: type & surgical &/or prosthetic management of

• Medical

• Speech Therapy

• Parents’ Concerns/Perspective

• School History (including learning issues)

• Psychological Issues

• Feeding/swallowing

• Peer Interactions

Assessment-HistoryType of Cleft/Surgeries/Prosthesis

• Type of Cleft: - note type of cleft (i.e., left cleft lip & palate)

• Surgeries Related to Cleft/VPI/A: - note surgeries regarding primary repair of cleft - note secondary surgeries in regard to VPI/A - note surgeries that may negatively impact VPA (i.e., tonsillectomy &/or adenoidectomy/T&A)

• Prosthetic Management of Cleft/VPI: - note any prosthesis used in regard to cleft/VPI

(i.e., palatal obturator, palatal lift)

Assessment-History

• Medical: Pregnancy Birth Newborn period Other conditions: heart congenital anomalies Significant illnesses/diseases Audiological

Assessment-History

• Speech Therapy: Enrollment: previous/ current length of enrollment # of sessions per week length per session group/ individual/combination Goals/Progress

Treating SLPs name

Results of Previous Evaluations

Assessment-History

• Parents’ Concerns/Perspective: Start with a general question: “How do you feel (name) is doing

with communication/speech?”

Follow-up with specific questions regarding: understandability,

articulation skills, hypernasality/NAE, voice, language skills

Assessment-History

• School History: Name of School

Grade Enrolled Regular Education/Special Education (or combination) Therapies Enrolled in Special Classes/Educational Help Receive Any teacher concerns regarding learning Results of recent reports/grades

Assessment-History

• Psychological Issues:

-Obtain results of any psychological, educational &/or IQ

testing, if available.

Assessment-History

• Feeding/Swallowing: -Inquire as to any history of difficulty with: sucking, chewing, swallowing

-This includes both liquids & solids.

- Any history of nasal regurgitation of liquids -Any issues with textures, temperatures, spiciness/blandness

- Swallow studies/Oral Pharyngeal Motility (OPM) studies

- History should be from birth to current age

Assessment-History

• Peer Interactions:

- First find out if the child has opportunities for peer

interactions

-Then find out if they have age-appropriate interactions

with their peers or if they have difficulties

Determining Nasal Patency

• Need to determine patency (airflow) of each nostril

• Need to determine patency for both breathing & production of nasal sounds

• If airflow is restricted or obstructed, it may mask SEVERITY &/OR INCIDENCE of resonance/NAEs

Determining Nasal Patency cont’d.

• Procedure:

1. Tell the patient to blow their nose.

2. Place the mirror under both nostrils (or one

at a time).

3. Tell the patient to close their mouth & breath

out of their nose.

4. Keep the mirror under the nostrils.

5. Tell the patient to say /m/.


• Place the mirror under both nostrils (or 1 at a time)


• Tell the patient to close their mouth and breathe out of their nose.


• Keep the mirror under the nostrils & tell the patient to say /m/.


• Variability in Responses


• Recording responses/information

Recording Nasal Patency Information

Nasal Obstruction: Right Nostril Occluded Left Nostril Occluded

a. Inhalation/exhalation none partial complete none partial complete

b. Sustained /m/ (3 secs.) none partial complete none partial complete

(Circle response)

Assessment-Articulation

• Intent of Articulation Assessment:

1. To obtain as much information as possible regarding articulation abilities.

Assessment-Articulation cont’d.

• Intent of Articulation Assessment cont’d.: 2. Use information not only to diagnose articulation/phonological

deficit/disorder BUT: a. Determine possible causes for deficit/ disorder b. Determine if attempt to use &/or use enough high pressure consonants to determine VP adequacy c. Determine if compensatory articulations are being used d. Help determine prognosis for improvement with/without speech therapy


• General Guidelines:

It is very important to watch the face/nose/mouth!

Allows you to observe: nasal grimace, incorrect placement, facial/neck tension etc.

True for both assessment & therapy.


• General Guidelines cont’d.:

Watch for lip & tongue mobility &/or restrictions.

Watch for dental abnormalities which might impact

correct sound production. This includes dental

appliances.

Watch for respiratory abnormalities.


• Guidelines:

1. Transcribe the entire production phonetically

including correct productions.

2. Note if response was spontaneous or imitative.


• Guidelines cont’d.:

3. Use “narrow phonetic transcriptions” for

errors not transcribable with normal

phonetic symbols.

Other Narrow Transcriptions

• Nasal Air Emission / /• Denasal / / • Nasalized Resonance[ ]• Unaspirated [ ]• Unreleased [ ]• Interdental [ ]• Lateralized [ ]

Other Narrow Transcriptions

• Transcription Symbols for Compensatory Articulation Errors



4. Note any vowel errors.

5. If more than just a few nasal air emissions (NAE)

occur, count as errors when scoring.



6. Do stimulability testing.

7. Note any differences during conversational speech.

8. Rate the overall intelligibility/understandability of

speech.



9. Note any weak pressure consonants &/or

reduced intra-oral air pressure.


• Test Selection:

Consider age of patient, language abilities etc.

Want a test that will keep the patient’s interest.

Want to assess sounds in as many positions as possible.

Want to assess as many consonant blends as possible.

Compensatory Misarticulations

• Learned articulation errors• Are mostly errors of PLACEMENT• Are typical to those with “cleft palate speech”• Develop as a means or strategy to overcome

structural difficulties due to the cleft• Are used to attempt to obtain valving for high

pressure consonants• Become part of child’s phonology• Can be very persistent

Types of Compensatory Misarticulations

• Glottal Stops• Laryngeal Stops• Pharyngeal Stops• Mid-dorsum Palatal Stops• Laryngeal Fricatives• Pharyngeal Fricatives• Velar Fricatives• Mid-dorsum Palatal Fricatives• Posterior Nasal Fricatives• Laryngeal Affricates• Pharyngeal Affricates• Mid-dorsum Palatal Affricates• Posterior Nasal Affricates

Types of Compensatory Misarticulationscont’d.

• Atypical Backing of /l/• Atypical Backing of /n/• Atypical Backing of /r/• Novel or idiosyncratic misarticulations

Glottal Stop / /

• Most common error• Normal sound in many languages

– English: vowel initiation

• Voiced Stop consonant with glottal placement• Laryngeal / Vocal cord valving

– Adduct– Pressure build-up below glottis

GLOTTAL STOP / /

• Greater pressure builds up– Consonant substitution > vowel initiation

• Excessive tension– Lower vocal tract– > intense opening / closing vocal cords– Ventricular vocal cords adduct / contact

Glottal Stop / /• Substituted: whole class of stops• Frequently co-articulated

– One manner of production– Two places of production

• Deviant / nonphonemic place effects manner

• Perceptually distinct – Pharyngeal stop / omission

Glottal Stop / /

Laryngeal Stop• Substitution for stop sounds• Base of tongue

– Moves posteriorly toward PPW (posterior pharyngeal wall)

– Epiglottis contacts PPW• Momentarily blocking airstream

• Larynx thought to move– Superiorly– Assist stopping airflow

Pharyngeal Stop• Lingua-pharyngeal consonant articulation

– Contact: tongue base to PPW– Pressure build-up / Sudden release

• Manner of production: Stop/Plosive• Contact: high or low• Substitution for /k/ , /g/• Not used as co-articulation• Voiced / / or unvoiced / /

Pharyngeal Stop

Mid-Dorsum Palatal Stop

• Stop consonant made in approximate place of “y”• Mid-section of tongue (dorsum) contacts mid-section of

palate• Typically substituted for /t/ or /k/ (voiceless) & /d/ or /g/

(voiced)• Perceptually is a cross between /t-k/ or /d-g/• May represent a place compromise between anterior &

posterior• May have been learned to use tongue to occlude palatal

fistula• Only mid-dorsum compensatory articulations are not

behind the uvula for place of articulation• Voiced / / or unvoiced / /

Laryngeal Fricative

• Substitution for fricative sounds

• Tongue base – Posterior

– Pushes epiglottis toward PPW

– Narrows airstream

• Constriction– Epiglottis & PPW

• Larynx moves up

• Variant– Pharyngeal fricative

Pharyngeal Fricative

• Lingua-pharyngeal fricative articulation• Tongue moves posteriorly toward PPW• Dorsum of tongue flattened• Constriction of airstream = frication• Substituted: fricatives & affricates• Co-articulation• Voiced / / or unvoiced / /

Pharyngeal Fricative

Velar Fricative

• Fricative production made at back velar for place of articulation

• Similar to /k/ or /g/ but tongue isn’t touching the palate

• Common substitution for sibilant fricatives or as distortion of /k/ or /g/ which then lack stop quality due to VP port leak

• Seen with dysarthria due to reduced range of movement in back of tongue

• Voiced / / or unvoiced / /

Mid-Dorsum Palatal Fricative

• Substitution for fricative sounds• Same positioning as mid-dorsum palatal stop but

positioning creates frication• May be place compromise to attempt to achieve

valving for airflow• Voiced / / or unvoiced / /

Posterior Nasal Fricative

• May be called velopharyngeal fricative• Turbulent VP fricative articulation occurring with small VP opening• Tongue moves back to help occlude the port (lingual assist), velum

approximates PPW but does not touch. Result is constricted airflow through the VP port; velum “flutters” against PPW or adenoid pad

• Perceived as frication/”snorting”• May occur as selective substitution for sibilant fricatives & affricates• Can be co-produced with any high pressure consonants• May be obligatory due to VPI/S or learned• Notable occurrence in individuals without clefts as phone specific

nasal emission• Symbol: / /

Laryngeal Affricate• Substitution: affricate sounds• Tongue base posterior

– Epiglottis

• Brief contact PPW• Then constrict airstream

– Stopping– Then frication

• Larynx moves superiorly

Pharyngeal Affricate

• Combines pharyngeal fricative & glottal stop• Less frequent in occurrence than glottal & pharyngeal

stops as well as pharyngeal fricatives• Mostly substituted for oral affricates “ch” & “j”• Dorsum of tongue moves posteriorly to contact PPW• Tongue contact constricts airstream to create stopping

followed by frication• Does not occur as co-articulation• Voiced / / or unvoiced / /

Mid-Dorsum Palatal Affricate

• Substitution for affricate sounds• Same positioning for mid-dorsum palatal stop

but positioning creates affrication• May be place compromise to achieve valving for

airflow• Voiced / / or unvoiced / /

Posterior Nasal Affricate

• Substitution for affricate sounds• Posterior dorsum of tongue & velum

– Create at VP valve• Stopping• Frication

• Audible NAE / Posterior Nasal Fricative• Amenable to speech treatment

– Tongue placement / Oral airflow

Atypical Backing of /l/

• Backed oral production of /l/• Move place of production back to velar area• Characteristic of cleft palate speech• Less impact on intelligibility than other

compensatory misarticulations• Symbol: / /

Atypical Backing of /n/

• Backed production of /n/• Placement may be anywhere on palate including

velum• Characteristic of cleft palate speech• Less impact on intelligibility than other


Atypical Backing of /r/

• Backed oral production of /r/• Placement is farther back, may be on velum• Characteristic of cleft palate speech• Less impact on intelligibility than other


Novel or Idiosyncratic Misarticulations

• Individuals will make their own unique misarticulations

• Idiosyncratic misarticulations tend to occur more in patients with cleft palate

• Novel/idiosyncratic misarticulations may include compensatory error co-articulated with normal placement production with manner error or placement may be also in error

Observations Regarding Compensatory Misarticulations

• Are active errors• Can be changed in therapy• Need to eliminate/reduce as many as possible

prior to FFVN for valid study• Are “stubborn”; therefore, really need to apply

the “new pathways” techniques/principles

Assessment-Resonance

• Resonance -hypernasality -assimilative hypernasality

-hyponasality

-cul-de-sac

-denasality

-mixed resonance

Assessment-Resonance cont’d.Definitions

• Resonance:

-vibratory response of a body or air-filled cavity to frequency of sound

-quality of voice resulting from sound vibrations in pharyngeal, oral &/or nasal areas

-refers to both perceptual & physical aspects


• Hypernasality:

-excess nasal resonance on vowels & vocalic consonants (i.e., “ir” as in “bird”), glides (“w, y”) or liquids (“l, r”)

-transcribed as: ~


• Assimilative Hypernasality:

-excess nasal resonance on vowels in presence of nasal consonants (“m, n, ng”)

-transcribed as: ~


• Hyponasality:

-reduction in nasal resonance

-affects nasal consonants

-is NOT opposite of hypernasality/can co-occur


• Cul-de-sac Resonance:

-blind pouch/passage with only one outlet

-resonance sounds as if in a cave

-created by trapping resonance (or sound) in back of mouth

-tongue placed back in mouth toward pharyngeal wall


• Denasality:

-nasal air flow is completely blocked

-prevents nasal air flow for nasal consonants

-/m/ sounds like /b/

-/n/ sounds like /d/

-”ng” (as in “ring”) sounds like /g/


• Mixed Resonance:

-combination of hypernasality, assimilative hypernasality, hyponasality, &/or cul-de-sac resonance

-can have any combination

-severity may vary between resonance types

Assessment-Resonance cont’d.Procedure

• Rating Scale: Numerous rating scales exist

Ratings are usually descriptive & numerical

Rating is SUBJECTIVE

CMHC currently uses a 7-point scale

CPCF Journal (January 2008) article shows how to convert various scales to a 4-point scale


• Rating Scale cont’d.:

CMHC 7-point rating scale:

7 6 5 4 3 2 1

None Slight Mild Mild-Mod Mod Mod-Sev Severe


• Hypernasality: Areas to Assess: Spontaneous Speech Sample

Sustained Vowel

Sentence Imitation task


• Hypernasality cont’d.: Areas to Assess: Spontaneous Speech Sample


• Hypernasality cont’d.: Areas to Assess: Sustained Vowel /i/


• Hypernasality cont’d.: 1. Place glove on your hand.

2. Tell child you’re putting the glove on because “in a

little while I’m going to gently touch your nose”.

3. Tell child “we’re going to practice how long

we can say a sound”.

4. Tell child “right now my hand with the glove is

going to stay over here by me”.


• Hypernasality cont’d.:

4. Tell child “I want you to say /i/ for as long as you

can”.

5. Tell child “Let’s do it together”.

6. Tell child “Good! Now this time I want you to

say /i/ until my finger is on your side of the

table”.


• Hypernasality cont’d.: 7. Tell child “Now I want you to say /i/ again for as

long as you can (until my finger is on your

side of the table). While you say /i/, I’m going

to gently open & close your nose”.


• Hypernasality cont’d.: Areas to assess: Sentence Imitation Task


• Hypernasality cont’d.: 1. Tell child: “I want you to say what I say”.

2. Say “I see a big black dog”.

3. “Say it again”. “Good”

4. Do the same with the other 2 sentences:

“Put your feet by the seat.”

“He has a beet to eat.”


• Hypernasality cont’d.: Sentence Imitation Task cont’d.


• Assimilative Hypernasality: Area to assess: Sentence Imitation Task


• Assimilative Hypernasality cont’d.: Area to Assess: Sentence Imitation Task cont’d.


• Assimilative Hypernasality cont’d.: 1. Tell child: “I want you to say what I say”.

2. Say “Hand the mean dog some meat”.

3. Say “The swing is neat and clean”.


• Hyponasality: Areas to Assess: Sustained nasal /m/

Sentence Imitation Task


• Hyponasality cont’d.: 1. Tell child: “I want you to say what I say”.

2. Say “My mama makes lemon jam”.

3. Say “Nancy is a nurse”.


• Other Resonance Types: Cul-de-sac, denasality, mixed resonance

Specific stimuli not used

Rate/make observations regarding while assessing other resonance areas & articulation as well as during conversational speech


• Infant-Toddler Assessment: 1. SLP rates severity of overall hypernasality in spontaneous speech.

2. SLP rates severity of overall hyponasality in spontaneous speech.

3. SLP asks parents to rate severity of hypernasality.

4. SLP asks parents to rate severity of hyponasality.

5. SLP asks if parents perceive any CHANGES in resonance. If so, when & how?

Assessment-Nasal Air Emissions (NAE)

• Nasal air emissions (NAE):

-audible

-inaudible

-nasal grimace

-nasal turbulence/rustle

Assessment-NAE cont’d.

• Audible Nasal Air Emissions:

-oral consonants produced (emitted) through the nose

-airstream is heard from the nose

-transcribed as: ~


• Inaudible Nasal Air Emissions:

-oral consonants produced through the nose

-not heard perceptually

-detected by mirror exam


• Nasal Grimace: (NG) -noticeable movement of nose during speech -movement may occur at nares, mid-nose, nasal bridge

-movement may be unilateral or bilateral

-movement occurs in attempt to achieve velopharyngeal closure

-movement is subconsciously used to move oral sound back to oral cavity from nasal cavity


• Nasal Turbulence/Rustle: (NT)

-oral consonant sound occurs during partially opened velopharyngeal valve

-air flow is turbulent with noted noise/rustle

Assessment-NAE cont’d.Procedure

• Nasal Air Emissions-Audible & Inaudible: Areas to Assess: Isolation

CV Syllables Phoneme-Loaded Sentences Stop/Plosive Fricative/Affricate

Mixed Nasal/Oral Loaded Words & Sentence(s)

Conversational Speech

Single High Pressure Consonant Words (IPAT)

Stimulability for Correction


• Area to Assess: Isolation


• Isolation: 1. Tell child “we’re going to say some sounds”.

2. “First we will do them without my mirror.”

3. “Then we will do them with my mirror.”

4. “Say /s/”.


• Isolation cont’d.: 5. “Say /p/”.

6. “Say /t/”.

7. “Say /k/”.

8. “Say “sh”.


• Isolation cont’d.: 9. “Now let’s do them again with my mirror”.

10. Repeat each sound while holding the mirror under

the nostril(s).


• Area to Assess: CV Syllables


• CV Syllables: 1. Tell child “we’re going to say some more sounds”.



4. “Say /sa/”.


• CV Syllables cont’d.: 5. “Say /pa/”.

6. “Say /ta/”.

7. “Say /ka/”.

8. “Say “sha”.


• CV Syllables cont’d.: 9. “Now let’s do them again with my mirror”.

10. Repeat each sound while holding the mirror under

the nostril(s).


• Areas to Assess: Phoneme-Loaded Sentences


• Phoneme-Loaded Sentences: 1. Tell child “now we’re going to say some sentences”.



4. “Say ‘Peter has a paper puppy”.


• Phoneme-Loaded Sentences cont’d.: 5. “Say ‘Buy a baby bib’.”

6. “Say ‘Tell teddy to try’.”

7. “Say ‘Daddy did the dishes’.”

8. “Say ‘Katie likes cookies’.”

9. “Say ‘Go get a bigger egg’.”


• Phoneme-Loaded Sentences cont’d.: 10. “Now let’s do them again with my mirror”.

11. Repeat each of the plosive-loaded sentences

while holding the mirror under the nostril(s).


• Phoneme-Loaded Sentences cont’d.: 12. “Now we have some more sentences to do”.

13. “Say ‘Silly Sue eats icicles’.”

14. “Say ‘Zippers are easy to close’.”

15. “Say ‘Should I wash the dishes?’.”

16. “Say ‘The garage hid the treasure’.”


• Phoneme-Loaded Sentences cont’d.: 17. “Say ‘Chad’s teacher was at church’.”

18. “Say ‘Jack wore a soldier’s badge’.”

19. “Say ‘Feed five frogs fish food’.”

20. “Say ‘Vic veered everywhere’.”

21. “Say ‘Thank you for the birthday present’.”


• Phoneme-Loaded Sentences cont’d.: 22. “Now let’s do them again with my mirror”.

23. Repeat each fricative & affricate-loaded sentence

while holding the mirror under the nostril(s).


• Area to Assess: Mixed Nasal/Oral Loaded

Words & Sentence(s)


• Mixed Nasal/Oral Loaded Words & Sentence(s): 1. Tell child “say ‘hamper hamper hamper’.”

2. “Good! Now do it again as fast & as many

times as you can.”

3. “Now say ‘donna donna donna’.”

4. “Good! Now do it again as fast & as many times as you

can.”


• Area to Assess: Conversational Speech


• Conversational Speech: Areas to Rate/Observe in regard to NAEs:

Present vs. Absent

Pervasive vs. Inconsistent vs. Occasional

Nasal Turbulence

Nasal Grimacing


• Area to Assess: Single High Pressure

Consonant Words


• Area to Assess: Single High Pressure

Consonant Words cont’d.

Stimuli: Iowa Pressure Articulation Test

(IPAT)


• Iowa Pressure Articulation Test (IPAT): Single Items Two-Item Blends /-k-/ MONKEY _____ /-sm/ POSSUM _____ “-ker” CRACKER _____ /-g-/ WAGON _____ /-ks/ BOOKS _____ “-ork” FORK _____ /k-/ CAT _____ “-per” PAPER _____ “-sher” WASHER _____ /g-/ GIRL _____ /sk-/ SKY _____ /gr-/ GRASS _____ /t-/ TABLE _____ /sm-/ SMOKE _____ “-ger” TIGER _____ /-f-/ TELEPHONE _____ /sn-/ SNAKE _____ /-lf/ WOLF _____ /-f/ LEAF _____ /st-/ STOVE _____ /-z-/ SCISSORS _____ /kr-/ CRAYON _____ 3-Item Blends /-s-/ PENCIL _____ /sp-/ SPOON _____ /s-/ SOAP _____ /tr-/ TREE _____ /-mps/ STAMPS _____ “sh-” SHOE _____ /kl-/ CLOWN _____ /str-/ STRING _____ /-s/ BUS _____ /gl-/ GLASS _____ /-g/ PIG _____ /bl-/ BLOCKS _____ “-sh” FISH _____ /br-/ BROOM _____ “j-” JEEP _____ /dr-/ DRUM _____ /-k/ BOOK _____ /tw-/ TWELVE _____ “-sh-” DISHES _____ /pl-/ PLATE _____


• IPAT cont’d.:

1. Tell child “we’re going to same some words

without pictures”.

2. “I want you to say what I say.”

3. “Say ‘monkey’ , say ‘wagon’ etc.


• Area to Assess: Stimulability for Correction


• Overall Rating of Nasal Air Emissions: Present vs. Absent Audible

Inaudible

Pervasive/Inconsistent/Occasional

Nasal Turbulence

Nasal Grimace (describe)

Severity Rating: none/slight/mild/mild-moderate/moderate/moderate-severe/ severe


• Infant-Toddler Assessment: 1. SLP performs overall rating of nasal air emissions.

2. Note if stimulable for correction.

3. Note if could not test (CNT) or did not test (DNT).

Assessment-Velopharyngeal Adequacy (VPA)Procedure

• Intent: To PERCEPTUALLY determine VP

adequacy

Assessment-Velopharyngeal Adequacy (VPA) cont’d.

Procedure

• VP Ratings:

Velopharyngeally Adequate (VP/A)

or

Velopharyngeally Inadequate (VPI/A)


Procedure

• VP Ratings cont’d: Other possibilities: Borderline VPI/A

Questionable


Procedure

• VP Ratings cont’d.:

Other Possibilities cont’d.: Unable to determine at this

time

Could not test

Assessment-Language Procedure

• Intent: to determine if language skills are

age-appropriate

Assessment-Language cont’d.Procedure

• Guidelines for Test Selection: 1. Assess receptive & expressive skills

2. Choose an age/developmentally-appropriate test

3. With most patients, want in-depth testing (vs. screening)

Assessment-Language cont’d.Procedure

• Additional Information:

If there are time or cooperation restraints:

At CMHC we prioritize EXPRESSIVE over receptive due to the

greater depth of information gained

OR

We DEFER language testing to the treating SLP

Assessment-VoiceProcedure

• Intent: to assess voice for abnormalities in pitch,

volume, &/or quality

Assessment-Voice cont’d.Procedure

• Assessment of Pitch: Make observations regarding pitch level-high, low, normal

Note if vocal fry is present due to talking at bottom of pitch range.

Note if vocal strain is heard due to talking at top of pitch range.

Note if able to vary pitch or is the pitch range limited/monotonous.

Observe if using diplophonia (talking with 2 simultaneous pitch levels).

If time permits, attempt to modify level/range etc.

BE CAREFUL NOT TO CONFUSE HIGH PITCH WITH HYPERNASALITY!!! They may CO-OCCUR, but are not synonymous.


• Assessment of Volume: Note if volume is too soft/quiet, excessively loud,

cannot be maintained over time (varies).

FREQUENTLY low pressure (due to VP valve issues) reduces the volume &/or ability to maintain a consistent volume.

If time permits, attempt to modify volume.


• Assessment of Quality: Note if: hoarseness breathiness

huskiness raspiness

harshness

aphonic

Assessment-FluencyProcedure

• Intent: to assess if speech is fluent or dysfluent

Assessment-Oral Mechanism/Oral Peripheral ExaminationProcedure

• Intent: to assess oral mechanism for structure &

function deficits

Assessment-Oral Mechanism/Oral Peripheral Examination cont’d.

Procedure

• Selection of Protocol: formal or informal


Procedure

• Positioning of Patient: eye level at level of oral

cavity

seated, erect


Procedure

• Initial Observations: Note if cleft exists & type

(none, overt, submucous)


Procedure

• Initial Observations: Overt Cleft

• Note if lip &/or palate

• Note if unilateral (if so, note if right or left) or bilateral or midline or facial

• Note if complete or incomplete

• Note if repaired or unrepaired


Procedure• Initial Observations: Submucous Cleft Palate

• Note if bifid uvula

• Note if notch in hard palate

• Note if muscular diastasis

• Note if repaired or unrepaired

• Note if occult


Procedure

• Structures Assessed:

Lips Tongue

Nose Teeth

Mandible/Maxilla Alveolus

Hard Palate Soft Palate

Other


Procedure

• Functions Assessed:

Lip Movements

Tongue Movements

Soft Palate Movement


Procedure• Structures Assessed: Lips

• Assess/Observe: Symmetry scarring thinness/thickness continuity of muscle notching limited mobility/tight frenulum protruding premaxilla open resting posture lip pits


Procedure

• Functions Assessed: Lips

• Assess/Observe: protrusion

retraction

approximation


Procedure

• Structures Assessed: Tongue

• Assess/Observe: size

shape

scarring

lingual frenulum


Procedure

• Functions Assessed: Tongue

• Assess/Observe: protrusion

depression

lateralization

elevation-outside oral cavity

elevation-inside oral cavity

circling lips

clicking


Procedure

• Structures Assessed: Nose

• Assess/Observe: size/width shape

nostrils (opening & nasal alae)

tip nasal bridge

columella septum

scarring symmetry


Procedure

• Functions Assessed: Nose

• Assess/Observe: patency

obstruction


Procedure• Structures Assessed: Teeth

• Assess/Observe: occlusal relationship incisor relationship supernumerary teeth rotated teeth missing teeth crowding primary/permanent condition (cavities) appliances


Procedure

• Functions Assessed: Teeth


Procedure

• How to Assess Teeth:


Procedure

• Structures Assessed: Mandible/Maxilla

• Assess/Observe: micrognathia macrognathia protrusion retrusion arch formation/collapse hypoplasticity mid-face retrusion


Procedure

• Structures Assessed: Alveolus

• Assess/Observe: residual cleft

fistula


Procedure• Structured Assessed: Hard Palate

• Assess/Observe: repaired vs. unrepaired width shape/height of palatal vault scarring/fissures/protuberance surgical alterations fistula palpated notch coloring


Procedure• Structures Assessed: Soft Palate

• Assess/Observe: repaired vs. unrepaired bifid uvula zona pellucida length/width/thickness shape during phonation symmetry at rest & during phonation scarring/surgical alterations fistula


Procedure

• Functions Assessed: Soft Palate

• Assess/Observe: degree of movement

direction of movement

fluidity of movement

pharyngeal movement


Procedure

• Structures Assessed: Other

• Assess/Observe: tonsils

pharynx

epiglottis

craniofacial/other anomalies

(eyes, ears, hands, etc.)


Procedure

• Structures Assessed: Other cont’d.


Procedure

• Additional Assessment/Technique Information:

• Compare normal vs. abnormal

• Judgment improves with experience


Procedure

• Additional Assessment Technique/Information:

• Assessing infants & toddlers


Procedure

• Additional Assessment Technique/Information:

• Assessing the less cooperative patient

Assessment-Order ofRationale

• Order of Assessment: 1. History 2. Nasal Patency 3. Articulation 4. Iowa Pressure Articulation Test 5. Nasal Air Emissions-isolation, syllable, sentences, mixed words/sentences 6. Hyponasality 7. Assimilative Hypernasality 8. Hypernasality-sustained vowel, sentence imitation (9. Language) 10. Oral mechanism examination

Assessment-Order ofRationale cont’d.

• John Wesley saying:

Do all the good you can

By all the means you can

In all the ways you can

In all the places you can

To all the people you can

As long as ever you can


• Order of Assessment cont’d.: 1. History: I have reviewed medical chart/reports etc. prior to seeing

the patient, but I can ask caregivers questions while child plays with an age-appropriate toy (NOTE: gives me time to observe child).

2. Nasal Patency: need to establish as impacts articulation/resonance/NAE/VP adequacy test results

3. Articulation: If ALL I get done is this, I can at least make some observations regarding resonance,NAE, VP adequacy, voice, expressive vocabulary, ability to follow directions etc.


• Order of Assessment cont’d.: 4. Iowa Pressure Articulation Test: rather non-invasive test measure & can make additional observations similar to those on articulation test

5. Nasal Air Emissions: testing without the mirror is non-invasive/non-threatening -testing with the mirror MAY BE threatening to some patients

6/7/8. Hyponasality/Assimilative Hyponasality/Hypernasality: The first 2 are also non-invasive/non-threatening HOWEVER testing for HYPERNASALITY involves use of GLOVES. This can be stressful/threatening for many children.

If I were to START with tests involving GLOVES, I may lose the child entirely and, therefore, accomplish little testing & get minimal diagnostic information.


• Order of Assessment cont’d.: 9. Language: As covered previously, this is a lower priority than the other areas.

10. Oral Mechanism Examination: This is another area that may be stressful/threatening to the children. REMEMBER for most young children, people look in their mouths when they aren’t feeling well (i.e., strep test).

ALSO, although each discipline on the team looks in the child’s mouth for a different purpose (i.e., dental vs. plastics vs. speech vs. ENT), usually at least one is able to accomplish this. In other words, if I CAN’T/DON’T get this information someone should have some of it.

OF COURSE, if you are the only person doing the assessment (not part of a team), this may be of a little more importance.

I always try to keep the GRAND SCHEME in mind. If I DON’T get this done, how negatively will it impact my diagnostics/ability to help the child? Am I better off DIFFERING till another time so as to not alienate the patient OR is it imperative that I accomplish this on this date?

Other Issues Impacting Cleft Lip/Palate &/or Velopharyngeal Inadequacy

• Possible Issues: feeding problems

development/cognition

educational issues

psychosocial issues

hearing problems

multiple anomalies

syndromes

genetic issues

Importance of the Team Approach to Treatment

• Why team management?

Benefit for the patient/family

Benefit for the professionals

Importance of Team Approach to Treatment cont’d.

• The GREATEST IMPORTANCE is that team care helps to provide the BEST OUTCOME for the patient!

Guidelines for Referrals for Perceptual &/or FFVN (Instrumental) Evaluations

• Perceptual

• FFVN

Perceptual Guidelines including Articulation

• Perceptual Evaluation performed within 6 months of FFVN

• Can be prior to study or same day of

• Scheduling variables: behavior, fatigue, time factor (distance traveled)

• Uses some high pressure consonants

• Validity of study

• Actually attempting to use the palate

Necessary Therapy Guidelines

• A good solid course of therapy should be provided prior to consideration for either perceptual or FFVN evaluation.

• At least one individual, 45-minute session per week for a minimum of 4 months, but preferably longer.

• The more high pressure consonants the child has or is attempting, the more valid the study, the more likelihood we will be able to truly help them.

Age Guidelines

• Majority are at least 4 years of age or older

• Cooperation

• High pressure consonants

• Age normally distinguish oral vs. nasal sounds (2 years old)

FFVN Teams at CMHC

• With Plastic Surgery• 3 speech/language

pathologists (SLP)• Claudia Magers, MS,

CCC-SLP• Sally Helton, MS,

CCC-SLP• Sabrina Wallace, MS,

CCC-SLP

• With ENT• 1 SLP• Claudia Magers, MS,

CCC-SLP

Referral Guidelines for FFVN

• Refer patients:

• Suspect velopharyngeal inadequacy (VPI/A)

• Suspect nasal obstruction

• Who present with disorders of vocal production (pitch, quality, intensity)

• Who present with possible or known disorder of structure &/or function of larynx

Referral Guidelines for FFVNSuspect Velopharyngeal Inadequacy

• Cleft Palate

• Neurological impairments, especially with oral-motor involvement

• Pre-tonsillectomy &/or adenoidectomy at high risk for VPI/A following surgery

• Post-tonsillectomy &/or adenoidectomy

Referral Guidelines for FFVNSuspect Velopharyngeal Inadequacy

cont’d.• Hypernasal vocal resonance

• Speech impairment including compensatory articulations, reduced intra-oral air pressure, &/or nasal air emissions

• Pre-maxillary advancement at risk for VPI/A following advancement

Referral Guidelines for FFVNSuspect Nasal Obstruction

• Hyponasal or denasal vocal resonance

• Post-pharyngeal flap surgery

• Pre-tonsillectomy &/or adenoidectomy

• Obstructive Sleep Apnea

Referral Guidelines for FFVNPresent with Vocal Disorders

• Affecting:

• Pitch

• Quality

• Intensity

Referral Guidelines for FFVNPresent with Laryngeal Disorder

• Possible or known disorder of structure &/or function of larynx

• i.e., vocal cord nodules, polyps

• i.e., vocal cord dysfunction

Guidelines Impact on Success of Studies

• Allow to be highly successful in completion of valid studies

• Don’t do unnecessary studies

• “Don’t burn bridges”

• Applies to both perceptual & age guidelines

Guidelines for Referral for Perceptual &/or FFVN (Instrumental) Evaluation

• If in doubt, give us a call!

• At 816-234-3677 ask to speak to Claudia Magers, MS, CCC-SLP (Toll Free: 1-888-239-8152)

• At 913-696-5750 ask to speak to either Sally Helton, MS, CCC-SLP or Sabrina Wallace, MS, CCC-SLP (Toll Free: 1-888-460-6432)

Guidelines for Referral to Children’s Mercy Hospitals & Clinics Cleft Palate/Craniofacial

Teams• # of Teams/Plastics Surgeons: 3 Virender K Singhal, MD, MBA Shao Jiang, MD Alison Kaye, MD

Location of Services: Children’s Mercy Hospital, 24th & Gillham Rd., Kansas City, Missouri Children’s Mercy South/College Blvd. Clinics 5808 W. 110th St./5520 College Blvd. Overland Park, Kansas

Contact Person for Scheduling: Stephanie Taylor, Cleft Palate Coordinator 816-234-3677 (Hearing & Speech @ CMHC @ Gillham Rd.) Toll Free: 888-239-8152

Final Thoughts

• Partnership:

-CMHC SLPs are in partnership with you the treating SLP

-we all ultimately want the best outcome possible for these children

Contact Information

• Sally Helton

Hearing & Speech

913-696-5756 (direct line)

[email protected]

Initial contact: by phone

Authorization/Releases

“The Bottom Line”

• I view these children as jigsaw puzzles. They come with the all the pieces and it is my job to figure out how they fit together.

Closing

Good luck with your diagnostics & therapy for your patients/students with cleft lip & palate &/or VPI!

Cleft Palate &/or Velopharyngeal Inadequacy Assessment or How to Determine Nose vs. Mouth Sounds

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