DIAGNOSIS, EVALUATION
AND THERAPY PLANNING
FOR VELOPHARYNGEAL
INSUFFICIENCY
Virginia Dixon-Wood, MA CCC-SLP
University of Florida Craniofacial Center
UF Speech and Hearing Clinic
Common Misconceptions
• Any speech pathologist can treat
children with VPI
• Hypernasality is the major speech
problem
• Speech therapy won’t help until
surgery is done
• VPI is a voice disorder
• Refer to ENT or neurologist
Insufficiency vs. Incompetency
• Structurally based -cleft palate,
submucous cleft
• Motor based - stroke, cerebral palsy,
low tone, TBI
• Mix- VCFS (22q-)
PRE-NATAL COUNSELING
• Cleft lip only
• Potential for cleft palate based
on severity (width) of cleft lip
• Up to 50% of families now know
prenatally
• In the long run, families do
much better
Birth to 6 months
• Feeding instruction and counseling
• Speech and Language development
• Hearing related issues
SPEECH COUNSELING
• Many children may never need
speech therapy
• Palate closure at 8-12 mo.
• Six month speech evaluations
• Parent counseling
6 months- 1 year
• REEL Scale 2
Receptive-Expressive Emergent
Language Scale – Bzoch
Birth to 3 years
6 months – 1 year
• Discuss surgery (9-12 months)
• Parents expectations
• Surgery counseling
12 mo. - 2 years
• Begin phonological inventory
range of sounds
oral/nasal contrast
• REEL Scale – refer for EI
• Parent counseling
Stages of Speech Development
• Vocalizations - birth
• Babbling - C+V repetition, 3 mo.
• Jargon - mixed C+V, 8 mo.
• First “true word”- 10-12 mo.
• Two word combinations - 18 mo.
Early Speech Development
• Non- cleft
• m, n
• d, b, p, g
• y, w
• Cleft
• m, n
• g
• y, h, w
Speech Characteristics of
the Young Child with
Possible VPI
• Delayed expressive language
development
• Very limited phonologic inventory m,n,h,y and some vowels
• Use of speech template
• Consistent nasal substitutions
Early Speech Development
Sound differentiation
Nasal vs. Oral
bye-bye vs. mye mye
bye-bye vs. i i
bye-bye vs. ? ?
Preschool
• Can assess palatal function
• Informally – predominately nasals
and vowels vs. combination of nasal
and pressure sounds
• Stimuli – baby, puppy, bye bye
• Formally – Measures of nasal
emission and articulation testing
Speech Characteristics
of VPI
• Glottal compensations
• Nasal substitutions
• Inappropriate nasal air emission
• Weak pressure consonants
• Hypernasality
Preschool
Evaluation of VPI:
Sound Production
Audible nasal emission
Glottal Compensations
Perceptual testing
• Nasal emission
• Articulation
• Resonance
• Intelligibility
Communicative Disorders
Test
Kenneth R.Bzoch
• Designed for specific speech
characteristics of cleft palate clients
• Articulation
• Resonance
• Nasal emission
• Voice - hoarseness, aspirate voice
quality
Audible nasal air emission
• Inappropriate air leakage through
the nose during the production of
consonants
• Tested on high pressure sounds plosives or continuants /p,b,s/
Nasal Air Emission
• Tests inappropriate nasal air escape
during the production of high
pressure consonants /p,b/
• Use visual or auditory feedback - ppaddle, mirror, listening tube
• Base 10 index
• Document change
Resonance
• Relationship between size of oral
and nasal resonating cavities
• Normal resonance – balanced
• VPI creates a increased nasal
resonating cavity
• Cold/allergies create a decreased
nasal resonating cavity
Resonance
• Perceived during vowel production
• Cul-de-sac testing
• Listener perception
Hypernasality
• Abnormal amount of nasal
resonance
• Negative impact on listener
• Perceived during vowel production
• Tested on vowels with oral
consonants
• beet, bit, bait, bought, boat
Hyponasality
• Too little nasal resonance
• Not perceived as negatively by
listener
• Common cold, allergies, sinusitis,
enlarged tonsils and adenoids,
pharyngeal flap
• Cul-de-sac testing
• Nasometry
Hypernasality
• Vowels with /b/
• If resonance is normal (oral)- there
should be no difference between the
2 productions
• Base 10 index
• Document change
Hyponasality
• Vowels with /m/
• If normal resonance, there should
be a difference (shift) between
words
• Base 10
• Document change
Significance
• Indexes of 3/10 or greater
• Do indexes match what you are
hearing in conversational speech?
• Impact on the child and/or family?
Voice
• Vowel prolongation- timed
• Aspirate -may be compensation to
conceal hypernasality
• Hoarseness - may be caused by
glottal compensations
Error Pattern Diagnostic
Articulation Test
• Developed for patients with cleft
lip/palate
• Based on manner of production
• Classifies many different errors - correct,
NE, distortion, simple/glottal
substitution, omission
• Error and articulation scores
• Documents change
Speech Sample
• Spontaneous single words
• Conversation
• Estimate a %
• Does it validate your other test
results?
Palatal Fistulae
• Opening along the suture line
• Assess size (mm)
• Document location
• Can be responsible for abnormal
articulation patterns
• Nasal emission
Fistula
• Important part of oral exam
• Anterior fistulae - impact on
articulation
• Nasal emission - may be
inconsistent or phoneme specific
• Resonance - may be normal
Fistula
• Recommendations based on speech
results:
surgical closure
obturate
do nothing
NOW WHAT ?
Creating the Treatment Plan
• Age
• Articulation vs. resonance
• Severity of articulation disorder
• What is interfering the most with
intelligibility
• Child and family reaction
• What can you treat?
SPEECH THERAPY
• WHAT?
• WHY?
• WHEN?
• HOW?
Treatment Plan
You have to understand the problem
before you can create a treatment
plan
Not understanding the problem can
create additional articulatory
compensations
Can waste valuable time and money
Treatment Plan
• Nasalized – diagnostic therapy to
see if child can impound oral
pressure (short term)
• Glottal compensations – help the
child learn to create oral breath
pressure
What NOT to do
• Muscle Training: (Cole, 1979)
• Indirect
• Semidirect
• Direct
What NOT to do
• Yules, 1968
• Subjects were able to reduce nasal
emission on short tests but that
establishment of performance in
automatic speech remained to be
demonstrated
What NOT to do
• McWilliams-no evidence that muscle
training had any impact on
improving speech or reducing nasal
emission
Misarticulations
• Judy Trost-Cardamone, 1997
• Obligatory errors - physical management
hypernasality, nasal emission, weak
pressure consonants
• Passive/Learned Errors compensatory errors, phoneme specific
Treatment Planning
• Child 1
•
Increase movement of articulators
•
Vowels
•
Increase intelligibility /m,n,y,h,w,l/
•
Frication
•
Pressure sounds
Treatment Planning
• Child 2
• Develop oral air flow
• Vowels
• Increase intelligibility /m,n,y,h,w,l/
• Frication
• Pressure phonemes
Speech Therapy
• Delayed speech development in
young children but without glottal
compensations
• Nasal emission
distortion/unintelligible speech
• Poor articulatory movement
Speech Therapy
• Goal: Improve
articulation/intelligibility
• Hypernasality and nasal emission
are not priorities
• Improve movement of articulators
• Accurate vowel production
• Low pressure consonants
Speech Therapy
• Delayed speech development with
glottal compensation
Improve intelligibility
• Establish oral airflow - this is
imperative
• Can create “popping” or “clicking”
for pressure sounds
Speech Therapy
• Child with glottal compensations:
• Improve articulatory movements
• Accurate vowels
• Low pressure consonants - oral airflow
• Frication
• Plosives
Speech Therapy
• Glottal compensations
•
Sonorants
•
Unvoiced
•
Final position
Speech Therapy
• Glottal compensations-
Begin with ANTERIOR sounds
Speech Therapy
• Multisensory
• Not successful at duplicating what
they have heard
• Visual
• Tactile
• Kinesthetic
Speech Therapy
• Glottal Articulation
• TEACHING PLACEMENT IS NOT
ENOUGH
• CAN CREATE CO-ARTICULATIONS
Palatal Fistula vs. VPI
• Obturate fistula
• Speech therapy - 3-6 months
• Objective testing
VIDEOFLUOROSCOPY
• Poor candidates:
•
compensatory articulation
•
poor articulation skills
•
significant palatal fistula
•
very young or uncooperative
child
Impact of Articulation on
Velar Function
• Glottal articulation can “shut down”
palatal movement
• Often there is little movement of the
articulators as well
• Palatal fistulae can also impact velar
function