Cleft Palate &/or Velopharyngeal Inadequacy
Assessment
or How to Determine Nose vs. Mouth
Sounds
KSHA Conference Presentation
10/01/2010
Sally Helton, MS, CCC-SLP
Speech/Language Pathologist
Children’s Mercy Hospitals & Clinics
Kansas City, Missouri
Hearing & Speech Department
913-696-5756
Introduction
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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
Cleft Palate cont’d.
• Submucous cont’d.
-occult (hidden)
Cleft Palate cont’d.
• 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 Valve
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 Valve
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
Anatomy
(structure)
VP Insufficiency
(VPI/S)
Physiology
(movement)
VP Incompetency
VPI/C
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
Relationship of VPI/A Types cont’d.
• 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
Relationship of VPI/A Types cont’d.
• 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
• Language
• Articulation
• Voice
• Resonance
• Fluency
• Nasal Air Emissions
(NAE)
• Oral Mechanism/Oral
Peripheral Examination
• Velopharyngeal
Adequacy
Tools Needed for Assessment
• Tissues
• Articulation test & score
form
• Gloves
• Flashlight
• Mirror
• Reinforcers/Toys
• 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-History
Areas to Consider
• Cleft: type & surgical
&/or prosthetic
management of
• School History
(including learning
issues)
• Medical
• Psychological Issues
• Speech Therapy
• Feeding/swallowing
• Parents’
Concerns/Perspective
• Peer Interactions
Assessment-History
Type 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/.
Determining Nasal Patency cont’d.
• Place the mirror under both nostrils (or 1 at a
time)
Determining Nasal Patency cont’d.
• Tell the patient to close their mouth and breathe
out of their nose.
Determining Nasal Patency cont’d.
• Keep the mirror under the nostrils & tell the
patient to say /m/.
Determining Nasal Patency cont’d.
• Variability in Responses
Determining Nasal Patency cont’d.
• Recording responses/information
Recording Nasal Patency Information
Nasal Obstruction:
Right Nostril Occluded
a.
Inhalation/exhalation
b.
Sustained /m/ (3 secs.) none partial complete
(Circle response)
none partial complete
Left Nostril Occluded
none partial complete
none partial
complete
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
Assessment-Articulation cont’d.
• 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.
Assessment-Articulation cont’d.
• 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.
Assessment-Articulation cont’d.
• Guidelines:
1. Transcribe the entire production phonetically
including correct productions.
2. Note if response was spontaneous or imitative.
Assessment-Articulation cont’d.
• Guidelines cont’d.:
3. Use “narrow phonetic transcriptions” for
errors not transcribable with normal
phonetic symbols.
Other Narrow Transcriptions
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Nasal Air Emission /
/
Denasal / /
Nasalized Resonance[ ]
Unaspirated [
]
Unreleased [
]
Interdental [
]
Lateralized [
]
Other Narrow Transcriptions
• Transcription Symbols for Compensatory
Articulation Errors
Assessment-Articulation cont’d.
• Guidelines cont’d.:
4. Note any vowel errors.
5. If more than just a few nasal air emissions (NAE)
occur, count as errors when scoring.
Assessment-Articulation cont’d.
• Guidelines cont’d.:
6. Do stimulability testing.
7. Note any differences during conversational speech.
8. Rate the overall intelligibility/understandability of
speech.
Assessment-Articulation cont’d.
• Guidelines cont’d.:
9. Note any weak pressure consonants &/or
reduced intra-oral air pressure.
Assessment-Articulation cont’d.
• 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
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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
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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 Misarticulations
cont’d.
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•
•
•
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
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•
•
•
•
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
•
Larynx moves up
– Posterior
•
Variant
– Pushes epiglottis toward
PPW
– Narrows airstream
Constriction
– Epiglottis & PPW
– 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
compensatory misarticulations
• Symbol: / /
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
compensatory misarticulations
• Symbol: / /
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
Assessment-Resonance cont’d.
Definitions
• Hypernasality:
-excess nasal resonance on vowels & vocalic
consonants (i.e., “ir” as in “bird”), glides (“w, y”)
or liquids (“l, r”)
-transcribed as: ~
Assessment-Resonance cont’d.
Definitions
• Assimilative Hypernasality:
-excess nasal resonance on vowels in presence
of nasal consonants (“m, n, ng”)
-transcribed as: ~
Assessment-Resonance cont’d.
Definitions
• Hyponasality:
-reduction in nasal resonance
-affects nasal consonants
-is NOT opposite of hypernasality/can co-occur
Assessment-Resonance cont’d.
Definitions
• 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
Assessment-Resonance cont’d.
Definitions
• 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/
Assessment-Resonance cont’d.
Definitions
• 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
Assessment-Resonance cont’d.
Procedure
• Rating Scale cont’d.:
CMHC 7-point rating scale:
7
None
6
5
Slight Mild
4
3
Mild-Mod Mod
2
1
Mod-Sev Severe
Assessment-Resonance cont’d.
Procedure
• Hypernasality:
Areas to Assess: Spontaneous Speech Sample
Sustained Vowel
Sentence Imitation task
Assessment-Resonance cont’d.
Procedure
• Hypernasality cont’d.:
Areas to Assess: Spontaneous Speech Sample
Assessment-Resonance cont’d.
Procedure
• Hypernasality cont’d.:
Areas to Assess: Sustained Vowel /i/
Assessment-Resonance cont’d.
Procedure
• 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”.
Assessment-Resonance cont’d.
Procedure
• 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”.
Assessment-Resonance cont’d.
Procedure
• 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”.
Assessment-Resonance cont’d.
Procedure
• Hypernasality cont’d.:
Areas to assess: Sentence Imitation Task
Assessment-Resonance cont’d.
Procedure
• 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.”
Assessment-Resonance cont’d.
Procedure
• Hypernasality cont’d.:
Sentence Imitation Task cont’d.
Assessment-Resonance cont’d.
Procedure
• Assimilative Hypernasality:
Area to assess: Sentence Imitation Task
Assessment-Resonance cont’d.
Procedure
• Assimilative Hypernasality cont’d.:
Area to Assess: Sentence Imitation Task cont’d.
Assessment-Resonance cont’d.
Procedure
• 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”.
Assessment-Resonance cont’d.
Procedure
• Hyponasality:
Areas to Assess: Sustained nasal /m/
Sentence Imitation Task
Assessment-Resonance cont’d.
Procedure
• 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”.
Assessment-Resonance cont’d.
Procedure
• 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
Assessment-Resonance cont’d.
Procedure
• 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: ~
Assessment-NAE cont’d.
• Inaudible Nasal Air Emissions:
-oral consonants produced through the nose
-not heard perceptually
-detected by mirror exam
Assessment-NAE cont’d.
• 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
Assessment-NAE cont’d.
• 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
Assessment-NAE cont’d.
Procedure
• Area to Assess: Isolation
Assessment-NAE cont’d.
Procedure
• 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/”.
Assessment-NAE cont’d.
Procedure
• Isolation cont’d.:
5. “Say /p/”.
6. “Say /t/”.
7. “Say /k/”.
8. “Say “sh”.
Assessment-NAE cont’d.
Procedure
• 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).
Assessment-NAE cont’d.
Procedure
• Area to Assess: CV Syllables
Assessment-NAE cont’d.
Procedure
• CV Syllables:
1. Tell child “we’re going to say some more sounds”.
2. “First we will do them without my mirror.”
3. “Then we will do them with my mirror.”
4. “Say /sa/”.
Assessment-NAE cont’d.
Procedure
• CV Syllables cont’d.:
5. “Say /pa/”.
6. “Say /ta/”.
7. “Say /ka/”.
8. “Say “sha”.
Assessment-NAE cont’d.
Procedure
• 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).
Assessment-NAE cont’d.
Procedure
• Areas to Assess: Phoneme-Loaded Sentences
Assessment-NAE cont’d.
Procedure
• Phoneme-Loaded Sentences:
1. Tell child “now we’re going to say some
sentences”.
2. “First we will do them without my mirror.”
3. “Then we will do them with my mirror.”
4. “Say ‘Peter has a paper puppy”.
Assessment-NAE cont’d.
Procedure
• 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’.”
Assessment-NAE cont’d.
Procedure
• 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).
Assessment-NAE cont’d.
Procedure
• 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’.”
Assessment-NAE cont’d.
Procedure
• 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’.”
Assessment-NAE cont’d.
Procedure
• 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).
Assessment-NAE cont’d.
Procedure
• Area to Assess: Mixed Nasal/Oral Loaded
Words & Sentence(s)
Assessment-NAE cont’d.
Procedure
• 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.”
Assessment-NAE cont’d.
Procedure
• Area to Assess: Conversational Speech
Assessment-NAE cont’d.
Procedure
• Conversational Speech:
Areas to Rate/Observe in regard to NAEs:
Present vs. Absent
Pervasive vs. Inconsistent vs. Occasional
Nasal Turbulence
Nasal Grimacing
Assessment-NAE cont’d.
Procedure
• Area to Assess: Single High Pressure
Consonant Words
Assessment-NAE cont’d.
Procedure
• Area to Assess: Single High Pressure
Consonant Words cont’d.
Stimuli: Iowa Pressure Articulation Test
(IPAT)
Assessment-NAE cont’d.
Procedure
•
Iowa Pressure Articulation Test (IPAT):
Single Items
/-k-/
/-g-/
/k-/
/g-/
/t-/
/-f-/
/-f/
/-z-/
/-s-/
/s-/
“sh-”
/-s/
/-g/
“-sh”
“j-”
/-k/
“-sh-”
MONKEY _____
WAGON _____
CAT
_____
GIRL
_____
TABLE
_____
TELEPHONE _____
LEAF
_____
SCISSORS _____
PENCIL
_____
SOAP
_____
SHOE
_____
BUS
_____
PIG
_____
FISH
_____
JEEP
_____
BOOK
_____
DISHES
_____
Two-Item Blends
/-sm/
/-ks/
“-per”
/sk-/
/sm-/
/sn-/
/st-/
/kr-/
/sp-/
/tr-/
/kl-/
/gl-/
/bl-/
/br-/
/dr-/
/tw-/
/pl-/
POSSUM
_____
BOOKS
_____
PAPER
_____
SKY
_____
SMOKE
_____
SNAKE
_____
STOVE
_____
CRAYON
_____
SPOON
_____
TREE
_____
CLOWN
_____
GLASS
_____
BLOCKS _____
BROOM
_____
DRUM
_____
TWELVE _____
PLATE
_____
“-ker”
“-ork”
“-sher”
/gr-/
“-ger”
/-lf/
CRACKER
FORK
WASHER
GRASS
TIGER
WOLF
_____
_____
_____
_____
_____
_____
3-Item Blends
/-mps/
/str-/
STAMPS
STRING
_____
_____
Assessment-NAE cont’d.
Procedure
• 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.
Assessment-NAE cont’d.
Procedure
• Area to Assess: Stimulability for Correction
Assessment-NAE cont’d.
Procedure
• 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
Assessment-NAE cont’d.
Procedure
• 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)
Assessment-Velopharyngeal Adequacy (VPA)
cont’d.
Procedure
• VP Ratings cont’d:
Other possibilities:
Borderline VPI/A
Questionable
Assessment-Velopharyngeal Adequacy (VPA)
cont’d.
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-Voice
Procedure
• 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-Voice cont’d.
Procedure
• 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-Voice cont’d.
Procedure
• Assessment of Quality:
Note if: hoarseness
huskiness
harshness
aphonic
breathiness
raspiness
Assessment-Fluency
Procedure
• Intent: to assess if speech is fluent or dysfluent
Assessment-Oral Mechanism/Oral Peripheral
Examination
Procedure
• Intent: to assess oral mechanism for structure &
function deficits
Assessment-Oral Mechanism/Oral Peripheral
Examination cont’d.
Procedure
• Selection of Protocol: formal or informal
Assessment-Oral Mechanism/Oral Peripheral
Examination cont’d.
Procedure
• Positioning of Patient: eye level at level of oral
cavity
seated, erect
Assessment-Oral Mechanism/Oral Peripheral
Examination cont’d.
Procedure
• Initial Observations: Note if cleft exists & type
(none, overt, submucous)
Assessment-Oral Mechanism/Oral Peripheral
Examination cont’d.
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
Assessment-Oral Mechanism/Oral Peripheral
Examination cont’d.
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
Assessment-Oral Mechanism/Oral Peripheral
Examination cont’d.
Procedure
• Structures Assessed:
Lips
Tongue
Nose
Teeth
Mandible/Maxilla Alveolus
Hard Palate
Soft Palate
Other
Assessment-Oral Mechanism/Oral Peripheral
Examination cont’d.
Procedure
• Functions Assessed:
Lip Movements
Tongue Movements
Soft Palate Movement
Assessment-Oral Mechanism/Oral Peripheral
Examination cont’d.
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
Assessment-Oral Mechanism/Oral Peripheral
Examination cont’d.
Procedure
• Functions Assessed: Lips
• Assess/Observe: protrusion
retraction
approximation
Assessment-Oral Mechanism/Oral Peripheral
Examination cont’d.
Procedure
• Structures Assessed: Tongue
• Assess/Observe: size
shape
scarring
lingual frenulum
Assessment-Oral Mechanism/Oral Peripheral
Examination cont’d.
Procedure
• Functions Assessed: Tongue
• Assess/Observe: protrusion
depression
lateralization
elevation-outside oral cavity
elevation-inside oral cavity
circling lips
clicking
Assessment-Oral Mechanism/Oral Peripheral
Examination cont’d.
Procedure
• Structures Assessed: Nose
• Assess/Observe: size/width shape
nostrils (opening & nasal alae)
tip
nasal bridge
columella septum
scarring
symmetry
Assessment-Oral Mechanism/Oral Peripheral
Examination cont’d.
Procedure
• Functions Assessed: Nose
• Assess/Observe: patency
obstruction
Assessment-Oral Mechanism/Oral Peripheral
Examination cont’d.
Procedure
• Structures Assessed: Teeth
• Assess/Observe:
occlusal relationship
incisor relationship
supernumerary teeth
rotated teeth
missing teeth
crowding
primary/permanent
condition (cavities)
appliances
Assessment-Oral Mechanism/Oral Peripheral
Examination cont’d.
Procedure
• Functions Assessed: Teeth
Assessment-Oral Mechanism/Oral Peripheral
Examination cont’d.
Procedure
• How to Assess Teeth:
Assessment-Oral Mechanism/Oral Peripheral
Examination cont’d.
Procedure
• Structures Assessed: Mandible/Maxilla
• Assess/Observe: micrognathia
macrognathia
protrusion
retrusion
arch formation/collapse
hypoplasticity
mid-face retrusion
Assessment-Oral Mechanism/Oral Peripheral
Examination cont’d.
Procedure
• Structures Assessed: Alveolus
• Assess/Observe: residual cleft
fistula
Assessment-Oral Mechanism/Oral Peripheral
Examination cont’d.
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
Assessment-Oral Mechanism/Oral Peripheral
Examination cont’d.
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
Assessment-Oral Mechanism/Oral Peripheral
Examination cont’d.
Procedure
• Functions Assessed: Soft Palate
• Assess/Observe: degree of movement
direction of movement
fluidity of movement
pharyngeal movement
Assessment-Oral Mechanism/Oral Peripheral
Examination cont’d.
Procedure
• Structures Assessed: Other
• Assess/Observe: tonsils
pharynx
epiglottis
craniofacial/other anomalies
(eyes, ears, hands, etc.)
Assessment-Oral Mechanism/Oral Peripheral
Examination cont’d.
Procedure
• Structures Assessed: Other cont’d.
Assessment-Oral Mechanism/Oral Peripheral
Examination cont’d.
Procedure
• Additional Assessment/Technique Information:
• Compare normal vs. abnormal
• Judgment improves with experience
Assessment-Oral Mechanism/Oral Peripheral
Examination cont’d.
Procedure
• Additional Assessment Technique/Information:
• Assessing infants & toddlers
Assessment-Oral Mechanism/Oral Peripheral
Examination cont’d.
Procedure
• Additional Assessment Technique/Information:
• Assessing the less cooperative patient
Assessment-Order of
Rationale
• Order of Assessment:
1.
2.
3.
4.
5.
History
Nasal Patency
Articulation
Iowa Pressure Articulation Test
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 of
Rationale 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
Assessment-Order of
Rationale cont’d.
• 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.
Assessment-Order of
Rationale cont’d.
•
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 noninvasive/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.
Assessment-Order of
Rationale cont’d.
•
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
• Uses some high pressure
consonants
• Validity of study
• Can be prior to study or
same day of
• Scheduling variables:
behavior, fatigue, time
factor (distance traveled)
• 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 FFVN
Suspect Velopharyngeal Inadequacy
• Cleft Palate
• Neurological impairments, especially with oralmotor involvement
• Pre-tonsillectomy &/or adenoidectomy at high
risk for VPI/A following surgery
• Post-tonsillectomy &/or adenoidectomy
Referral Guidelines for FFVN
Suspect 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 FFVN
Suspect Nasal Obstruction
• Hyponasal or denasal vocal resonance
• Post-pharyngeal flap surgery
• Pre-tonsillectomy &/or adenoidectomy
• Obstructive Sleep Apnea
Referral Guidelines for FFVN
Present with Vocal Disorders
• Affecting:
• Pitch
• Quality
• Intensity
Referral Guidelines for FFVN
Present 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: 1-888-2398152)
• 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)
shelton@cmh.edu
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!