KSHA Conference Presentation 10/01/2010

KSHA Conference Presentation 10/01/2010
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

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 Name: Sally Helton Education: BSE-1975-University of Kansas, Lawrence, Speech Pathology MS-1978-Southern Illinois University, Carbondale, Speech Pathology Years at CMHC: 26 years Years w/CPCF Team: 21 Years CMHC FFVN Team: 11 Years Member ACPA: 17 Primary Job Function: provide diagnostics & speech therapy to patients with cleft lip &/or palate &/or velopharyngeal inadequacy Other Job Functions: provide diagnostics & therapy for pediatric communication disorders including vocal cord dysfunction; mentor/cross-train new employees/students particularly in regard to cleft lip &/or palate/VPI

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 Diagnostic Assessment: Majority of presentation will cover diagnostics Other Issues: There are numerous other issues that may accompany CLP &/or VPI/A. 1. Important to be aware of to treat whole child. 2. Important to be aware of as SLP is frequently the first “stop” in the diagnostic process. Referrals to other professionals/disciplines may need to be made. Team Approach: Best clinical practice for CLP & VPI/A is a team approach. Referral Criteria: Will cover when a referral for more advanced assessment would be appropriate as well as referral information for our cleft palate teams. Overall, I would say the point of this presentation is to GET YOU CONNECTED to diagnostics for cleft lip &/or palate &/or VPI/A issues. It’s also to HELP YOU CONNECT DIAGNOSTICS to THERAPY for those of you who were able to attend my presentation last year on therapy.

Basic Terminology This is a brief review of basic terms or definitions so we can “all be on the same page”.

Cleft Lip A cleft of the lip which may be: -complete or incomplete
-unilateral or bilateral -extend to the nostril -extend to the alveolus SHOW PICTURES Complete: extends through entire lip, nostril & alveolus Incomplete: may be minor notch in vermillion or may involve entire lip, but not nostril or alveolus Unilateral: only on one-side, may be left or right most often on left Bilateral: occurs on both sides

Cleft Palate A cleft of the palate which may be:
-complete or incomplete -unilateral or bilateral SHOW PICTURES Complete: includes the hard palate to the incisive foramen Incomplete: only a portion of the palate (hard or soft) such as the velum (soft palate) Unilateral: only on one side, may be left or right Bilateral: occurs on both sides

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: cleft of the underlying structure of the palate, but the oral surface is intact; may involve muscles & nasal surface of the velum, but can also involve bony structure of hard palate Overt: identified by intraoral exam observe one or more of: bifid uvula: split velum zona pellucida: bluish area in middle of velum due to thin mucosa with absence of underlying muscle mass muscular diastasis: separation of palatal muscles inverted “V” shaped velum during phonation: due to muscular diastasis with abnormal muscle insertion into posterior edge of hard palate instead of into midline of velum notch in posterior border of hard palate: detect by palpation

Cleft Palate cont’d. Submucous cont’d. -occult (hidden)
Occult submucous cleft palate: -hidden/ not revealed -identified from nasal surface during nasopharyngoscopy -usually presents with same muscular deficiencies etc. as overt SMCP -diagnosis is only done if velopharyngeal inadequacy of unknown etiology (cause) exists (as no obvious physical velum abnormality is seen); in other words, will only do instrumental assessment if present with speech characteristic of VPI/A, but cannot determine cause visually

Cleft Palate cont’d. Variations Incidence Other Clefts
Classification Systems Variations: you can have different combinations of cleft lip & /or palate including unilateral cleft lip & bilateral cleft palate Incidence: 1 in 750 live births (doesn’t include: SMCP, bifid uvula) 2nd to Down Syndrome in incidence (1:660) Higher incidence of SMCP with isolated cleft lip (DON’T DISMISS as isolated cleft lip) Other Clefts: There are other types of clefts including facial & midline. Classification Systems: Several formal classification systems exist such as Veau’s, Kernahan & Stark’s, ACPA’s etc.

ACPA American Cleft Palate-Craniofacial Association
Comparable to ASHA, but: -includes CLP team members from several disciplines -is international in membership -much smaller group than ASHA (entire annual meeting is held in one hotel) - -IF ONLY DO ACPA, get AMERICAN CONCRETE PAVING ASSOCIATION (may be interesting, but not what we’re looking for) ON RESOURCE LIST (additional handout)

22q deletion Deletion of genetic material from chromosome 22
Other names: 22q11.2 deletion Shprintzen’s Syndrome Velo-Cardio-Facial Syndrome 22q11.2 deletion: specific site of deletion on q arm of 22nd chromosome Shprintzen’s Syndrome: Robert Shprintzen, Ph.D. noticed certain anomalies co-occurring (1974) Velo-Cardio-Facial Syndrome: describes 3 areas that may be involved: velum (soft palate): cleft, deep pharynx (77%) cardio (heart): heart defect; misplaced carotid arteries (76%) facial (face): broad nasal root, long nose, bulbous tip Progression of syndrome labels: Person “discovered” Descriptive of parts involved Genome project-what gene is on

22q deletion cont’d. Other manifestations Organ systems affects
Variable expression Incidence Significance in regard to education Other manifestations: (may include) learning, psychological, behavioral, developmental problems which may worsen over time (may be very subtle) Organ systems affected: affects all organ systems: immune deficiency (77%), hypotonia, hypo-calcemia (49%), kidney anomalies etc. Variable expression: term is “umbrella” term with many variations underneath; may include DiGeorge or Robin sequences but not necessarily and DiGeorge & Robin sequences don’t have to include 22q deletion Incidence: approximately 1:2000 Significance in regard to education: many cases go undiagnosed, education community is larger unaware of; potential of decrease in skills (language, learning etc.) over time & overall affect GIVE EXAMPLE CELF-P-2 SCORES SHOW BOOKS

Flexible Fiberoptic Video Nasopharyngoscopy (FFVN)
Invasive procedure used to evaluate the structure & function of the velopharyngeal mechanism during speech. Purpose is to not only see structure & any potential deficiencies, but also how the structure functions during speech.

Velopharyngeal Mechanism
Velo: velum/soft palate Pharyngeal: lateral & posterior pharyngeal walls Pharynx: part of throat between esophagus & nasal cavity Soft Palate: back 1/3 of palate (roof of mouth) portion without bone underneath Pharyngeal: inside walls of throat SHOW POSTER CHART WITH ANATOMY

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 Port is the actual area. SHOW ON POSTER

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 SHOW ON POSTER

Velopharyngeal Valve POINT OUT ANATOMICAL LANDMARKS

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 SHOW ON POSTER

Velopharyngeal Valve POINT OUT ANATOMICAL LANDMARKS

Velopharyngeal Inadequacy (VPI/A)
Generic term Refers to any abnormal velopharyngeal function Diagnosed perceptually (by listening) Occurs when something is wrong with velum & pharyngeal closure; thus, creating vowels &/or consonants that are emitted through the nose. Can also result in compensatory misarticulations that are specific to VPI/A. Various terms used over the years. This is the most agreed upon terminology & most used by those who specialize in the filed of cleft palate/velopharyngeal inadequacy. Originally proposed by Judith Trost-Cardamone, SLP. Refined over the years by her and others with ACPA.

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. As cannot distinguish perceptually, “generic” or “umbrella” term velopharyngeal inadequacy (VPI/A) is used.

Velopharyngeal Insufficiency (VPI/S)
Structural defect of the palate &/or pharyngeal area This is when VP closure does not occur due to structure. Unrepaired cleft palate (overt, submucous, or occult submucous) Palate may too short &/or stiff in movement. Lateral walls may not move. Posterior pharyngeal wall may not move. Pharynx may be too deep. Palate may have a notch/”seagull sign” where muscles are not connected (even after primary repair). May be due to unrepaired submucous or occult submucous cleft palate. Excessive tonsillar tissue may mechanically interfere with VP valve function. Project into pharynx between velum & soft palate; restrict medial movement of lateral pharyngeal walls; one tonsil larger than the other may push velum up on that side & cause uvula to deviate/adhere to large tonsil. (NOTICE DURING ORAL MECH EXAM) Adenoid atrophy/irregular adenoids (large, fissured, bulbous) Post-pharyngeal flap, sphincter pharyngoplasty, adenoidectomy. May use velo-adenoidal closure.

Velopharyngeal Incompetency (VPI/C)
Neurogenic impairment Movement disorder/motor planning Not structural Congenital, i.e., cerebral palsy Acquired: trauma (closed head injury) cerebrovascular accident (CVA) progressive disease such as ALS cerebral or brainstem tumors Dysarthria: oral-motor dysfunction with abnormal strength, range of motion, accuracy of speech muscles. Speech may be slow, slurred. Motor programming: apraxia of speech (difficulty executing/sequencing volitional oral motor movements, movements choose to make) Hypotonia of portion or all of VP valve. Stress Incompetence: velar fatigue while playing wind instrument (absence of VP dysfunction). Need more intraoral air pressure to play instrument than for speech. If sudden/only certain times, monitor for progressive neurological condition.

Velopharyngeal Mislearning
Functional disorder Faulty learning of articulation patterns Sound (phone) specific nasal air emission (s) Can also include VPI due to deafness, hearing impairment. May have normal structure. Phone or sound specific is frequently /s/, /z/. Functional errors that persist after surgical correction of structural deficiency. May occur following surgical repair of VPI/S. Just because provide the structure does not mean that the brain automatically knows how to use it. Needs to be trained. Need to lay down new pathways/new auditory awareness/feedback.

Relationship of VPI/A Types
Credit Kummer (share Trost-Cardamone graph-original graph laid out as 3 separate areas & didn’t show inter-relationship well) 3 types of VP Inadequacy are NOT mutually exclusive Patient can exhibit 1 type or any combination of all 3 types Notice that: part of each circle can stand alone part of each circle can overlap one of the other circles all 3 circles overlap in the middle (may need to draw a line/shade in darker due to print quality of black & white) IF YOU REMEMBER ANYTHING ABOUT VPI FROM TODAY, THIS IS WHAT IS MOST IMPORTANT AS IT WILL GUIDE YOUR THERAPY

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 I REALIZE I’M COVERING DIAGNOSTICS, BUT THIS IS A VERY IMPORTANT CONCEPT Example: If patient presents with VPI/S, speech therapy alone will not correct the problem. If there is a structural deficit, the patient cannot “override” it. This is true whether it is an unrepaired cleft palate or any of the other structural deficits; such as, a short palate after primary surgical repair, deep pharynx etc. THEY SHOULD, HOWEVER, BE ABLE TO LEARN CORRECT PLACEMENT OF SOUNDS, BUT NOT MANNER. If patient presents with VPI/C, surgical treatment will not correct the problem. Surgery cannot correct a motor planning or movement deficit such as apraxia, cerebral palsy. If patient presents with VPI Mislearning, surgical treatment will not correct the problem. If using sound specific nasal air emissions on /s/ (forcing sound through the nose), therapy is needed. Surgery will not correct this type of sound problem.

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 Diagnostic assessment should be performed by an SLP with specific training/experience in the area of VPI/A. This is usually done by the SLP on the Cleft Palate-Craniofacial Team. FFVN evaluations are usually done by a trained FFVN team which usually includes a physician (cleft palate surgeon/ENT doctor) & a VPI/A trained SLP SLP has acquired specific training for FFVN (above & beyond CLP/VPI). (CMHC has both kinds of teams). CLPC Team visit & FFVN may or may not be scheduled on the same day. HOWEVER diagnostic assessment may not include FFVN or instrumental evaluation because:

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. Remember, purpose of FFVN is to look at structure AND FUNCTION. If high pressure consonants aren’t being used or attempted to be used, the patient is doing very little to actually move the palate. Speech therapy should be done first to target acquisition of high pressure consonants in order to later have a valid FFVN study, if one is still needed.

Areas of Assessment History Articulation Resonance
Nasal Air Emissions (NAE) Velopharyngeal Adequacy Language Voice Fluency Oral Mechanism/Oral Peripheral Examination I’m going to cover all of these areas as they are usually part of a perceptual speech evaluation during a patient’s cleft palate/craniofacial team visit. The areas you may be able to assess may vary based on your work setting. You may have time &/or rule restrictions. However, it is possible to assess all of these areas without being a part of a CP/CF team. Additionally, special equipment is not needed to perform these assessments.

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) Tissues: tissues are needed for the nasal patency test Gloves: best to use powder-free non-latex gloves due to risk of allergic reactions -hands should always be washed (either hand sanitizer or with soap) after removing gloves as germs may come off during action of removing glove Flashlight: doesn’t need to be large, but should be bright; some people use animal-shaped flashlights Mirror: needs to be large enough to place under both nostrils BUT needs a SMALL LIP OR EDGE in order to be placed as close as possible to the upper lip under the nostrils Reinforcers/Toys: need reinforcers to keep child participating (i.e., duplos, games, Mr. Potato Head); need toys with younger child to observe play

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) I will be presenting the protocol that we use at Children’s Mercy. Other teams/facilities will use different protocols. Over the past several years, there has been a group of ACPA SLPs experienced in speech & cleft palate (Speech Parameters Group) who have been working on developing a UNIVERSAL SET OF PARAMETERS FOR ASSESSMENT. (CPCF Journal, January 2008) These parameters do not necessarily give the specific word stimuli, but do provide guidelines for the types of stimuli to be used & how to report outcomes. FOR EXAMPLE, in assessing hypernasality, words with only high vowels & no nasal consonants should be used. (ex. “peep” vs. “map”) The intent of the parameters group is to have universal guidelines that can be used across languages. This will then allow for more accurate collaborative data & research worldwide. Additionally, if patients move from one CPCF team to another, response comparisons will be more accurate. (APPLES TO APPLES COMPARISON VS. APPLES TO ORANGES)

Assessment-History Areas 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 This slide shows how there are a number of areas to be considered in working with this patient population. The amount of history that you gather/obtain may be dependent upon: -your work setting -your access to previous records -what information the family provides -if any information is provided by the treating SLP etc. You will want to have a form to record this information.

Assessment-History Type of Cleft/Surgeries/Prosthesis
- 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) Type of Cleft: You may have this information from previous report or you may be determining it at the time of assessment. - note structures involved (lip, alveolus, palate-hard &/or soft) - note laterality (left, right, bilateral) REMEMBER you can have combinations (i.e., left cleft lip & bilateral cleft palate) - You may be able to note if complete or incomplete (BUT if you can’t determine this, don’t worry about it)

Assessment-History Medical: Pregnancy Birth Newborn period
Other conditions: heart congenital anomalies Significant illnesses/diseases Audiological Medical: You will want to note anything unusual about the following areas: PREGNANCY: length, illnesses, premature labor, C-section (& why) BIRTH: weight, trauma, meconium staining, aspiration amniotic fluid NEWBORN PERIOD: length of hospitalization, need for NICU OTHER CONDITIONS: HEART: heart defects frequently go along with cleft palate (22q) This may “tip off” that SMCP may be involved. CONGENITAL ANOMALIES: frequently other anomalies go along with cleft palate (skin tags, lip pits, extra digits) SIGNIFICANT ILLNESSES/DISEASES: pneumonia (may be GERD related) hospitalizations AUDIOLOGICAL: A hearing test should be part of the evaluation, but do obtain history of hearing loss/tubes etc. THIS IS NOT AN INCLUSIVE LISTING!

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 In the best scenario the parent provides documentation (i.e., IEP, IFSP, evaluation report, Treatment Plan, Progress Report/Note). HOWEVER, this doesn’t happen very often. It is also surprising how many parents cannot answer these questions. They may not have a clue as to what has been targeted in therapy. Additionally, the patient/child may not know; although sometimes you can say “tell me what sound or words you’ve been working on”. If the parent does provide documentation, request to make a copy for your files. Also, make sure you follow proper procedures/release etc. protocol for your institution.

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 General Question: Some parents can provide quite a lot of information with a general question. You may need to “tailor” the wording (i.e., communication/speech) to the parent. Specific Questions: With many families you will need to ask more specific questions to gain information. You will probably need to give examples for each area. Understandability: “How much of the time do you understand (name)? 50%, 75%?”; “How well do strangers understand (name)?” Articulation Skills: “Do you notice sounds that (name) has trouble with? Have skills improved with speech therapy?” Hypernasality/NAE: This is an area where families are frequently confused. You may need to give specific examples. “Does (name) sound like he/she is talking through his/her nose?” (follow with demonstration); “Does (name) sound like he/she is plugged up/has a cold? “(follow with demonstration); “Does (name) produce oral (mouth) consonants thru his/her nose?” (follow with demonstration). THIS IS ALSO AN AREA FAMILIES FREQUENTLY DO NOT HEAR DUE TO “BRAIN ACCOMODATION.” Voice: “Does (name) ever sound hoarse? Does (name) ever talk at too high or too low a pitch level? Does (name) have trouble with volume-either too quiet or too loud?” Language Skills: “Do you have any concerns with (name’s) vocabulary, length of sentence, ability to get his/her point across, ability to understand directions? Have skills improved with language therapy?” Other Communication Concerns: “Do you have any other communication concerns?”

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 Name of School/Grade Enrolled: Ask parent(s) name of child’s school. If summer, note grade will be enrolled in the fall & date as such (i.e., 1st grade, Fall 2010). Regular/Special Education: Find out if child is enrolled in regular classroom, special education or combination. If you have a copy of the IEP this information should be available, but be sure to check. Some parents only provide goal pages of IEP. Therapies Enrolled In: besides speech therapy make notes regarding occupational, physical, music or other therapies. Special Classes/Educational Help Receive: make notes regarding any special classes/help such as reading, math etc. Teacher Concerns: ask about any concerns teacher(s) have expressed Report results/grades/testing results: obtain any recent test results, grades

Assessment-History Psychological Issues:
-Obtain results of any psychological, educational &/or IQ testing, if available. As with any of these areas, you may obtain results directly from parents, from medical charts, from educational files etc. Once again, follow the proper protocol of your institution including rules, releases, protected health information (PHI), HIPPA policies etc.

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 Be fairly specific in your questions. Most parents of toddlers/preschoolers will say their child is a “PICKY EATER”. You will need to obtain the parents description of “picking eating” to see if it truly meets that definition. A toddler/preschooler that only decides to eat one food for several days is not a “picky eater”, per se. Ask questions such as : What fruits does your child eat? Are those apples slices with or without the peel? (texture) Will your child eat applesauce, cottage cheese, oatmeal? (texture) Is your child able to drink liquids from an open cup, “sippy cup” etc.? I WANT TO GIVE CREDIT TO OUR CLPC TEAM NUTRITIONISTS FOR THE MAJORITY OF MY KNOWLEDGE IN REGARD TO THESE ISSUES. Nasal regurgitation is fairly common in infants with unrepaired palatal clefts, but can also continue after palate repair. Most commonly parents report its occurrence with items such as chocolate.

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 Opportunities for Peer Interactions: Inquire if they attend any of the following: - play with neighbors/relatives play groups - preschool parent’s day out - daycare - religious groups (i.e., Sunday school) - activities (i.e., gymboree, music, dance, sports) Inquire as to the ages of the “peers involved” as sometimes the children are not truly peers. (i.e., 2 year old attends daycare with all 5 year old children) Inquire as to how often/frequently interactions occur. May have interactions, but only 1 time per month. Inquire as to age-appropriateness of individual child’s interactions (i.e.., parallel play, interactive play). Inquire if child gets along well with peers or has trouble interacting.

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 PRIOR TO ARTICULATION/RESONANCE/NASAL AIR EMISISION ASSESSMENT YOU NEED TO DETERMINE NASAL PATENCY. YOU NEED TO DETERMINE THIS FOR EACH NOSTRIL. Nasal Patency: if nostrils are patent, air & nasal sounds can pass through. Mask Severity &/or Incidence: If there is an obstruction, the incidence of hypernasality may be reduced &/or the severity may be lessened. You may not even hear hypernasality or you might hear mild instead of moderate, for example. It may also diminish nasal air emissions, both audible & inaudible. Lack of nasal patency can influence test results; & therefore, perception of VP adequacy.

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/. Tell patient to blow nose: I don’t ask if they can blow their nose because I don’t want to give the option to say “no”/to refuse. I hand the patient a tissue and say “blow your nose”. I might tell them “we need to get all of the yucky (burgers, junk etc.) out of your nose”. If they refuse, I say “mom/dad can help” or I tell them “we can’t look at our picture books/play our games/get a prize until you blow your nose”. Many children with cleft palate/VPI have difficulty blowing their nose. Some young children don’t have the concept & blow out of their mouths. Many have trouble establishing pressure or force to blow their nose. I just try to get this accomplished “as best as they can”. CAUTION: Young children will frequently try to give you the dirty tissue when they are done. I try to direct them to throw it in the trash because: 1) I don’t usually have a glove on at this time & 2) that teaches them some responsibility. I might also have them hand it to the parent.

Place the mirror under both nostrils (or 1 at a time) Make sure your mirror is clean. Remember the caution to have a small lip or edge on the mirror. You can use different sized mirrors: 1. I prefer a compact mirror, but one I can place under both nostrils. SHOW MIRROR 2. Some people use larger round mirrors which can be helpful later when assessing for NAEs. 3. In the past I have used a dental mirror; however, due to size you can only place under one nostril at a time.

Tell the patient to close their mouth and breathe out of their nose. Initially, many children open their mouths when they see the mirror. As I hold the mirror under their nose, I say “close your mouth and breathe”. This is usually not very hard to accomplish, though sometimes I might show them how I can do it & fog (“make it cloudy”) the mirror. On this step, you are judging nasal patency during exhalation. You are looking for fogging from both nostrils. You want to judge each nostril separately & record your observations separately. You will then judge if the nostrils were PATENT, PARTIALLY OCCLUDED OR COMPLETELY OCCLUDED as based on the amount/degree of fogging. With practice, it will become easier to tell the difference between PARTIALLY and COMPLETELY occluded.

Keep the mirror under the nostrils & tell the patient to say /m/. Next, you want to check patency during production of a sustained /m/. Continue to hold the mirror under the nostrils. Tell the patient to say /m/. Have the patient sustain production for at least 3 seconds. Once again, judge the patency for each nostril. Use the same scale as before: PATENT, PARTIALLY OCCLUDED, COMPLETELY OCCLUDED.

Variability in Responses You may find variable responses not only for each nostril, but also see a difference between exhalation & production of sustained /m/. NOTE: At least partial occlusion is fairly frequent in this patient population due to the higher incidence of nasal congestion/drainage. Nasal congestion/drainage may be due to anatomical issues, allergies, &/or sensitivities to upper respiratory infections.

Recording responses/information You will want to record responses individually for both nostrils as well as for both exhalation & production of sustained /m/. On our protocol sheet we have it set up according to how we are facing the patient. In other words, we record the right nostril information on the LEFT side of the page & the left nostril on the RIGHT side of the page.

Recording Nasal Patency Information
Nasal Obstruction: Right Nostril Occluded Left Nostril Occluded Inhalation/exhalation none partial complete none partial complete Sustained /m/ (3 secs.) none partial complete none partial complete (Circle response) This is an example of our (CMHC) form. Note how the RIGHT nostril information is on the left of the LEFT nostril information. You may want to develop a form for your own use.

Assessment-Articulation
Intent of Articulation Assessment: 1. To obtain as much information as possible regarding articulation abilities. Obtain as much information as possible: The more information you have, the better your diagnostics. The better your diagnostics, the easier it will be to determine therapy goals & appropriate therapy techniques to utilize. THEREFORE not only should you obtain formal articulation testing results, but also make observations during spontaneous speech, language testing, & during assessment for hypernasality/NAE. THIS DOES NOT ONLY APPLY TO THIS POPULATION BUT TO ALL PATIENTS’ ARTICULATION ASSESSMENTS! NOTE ALL ERRORS. EX. Note production of /k/ in “cup” & “car”. Isn’t how test was normed, but provides the most information.

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 Obviously, information from assessment should allow you (if gathered enough information) to diagnose articulation/phonological deficits/disorders. Information should also help you to determine: Possible causes: For example, if most or all final consonants are omitted, it is most likely a phonological or rule-based cause. However, if the child has Class III occlusion & cannot make labiodental /f/ & /v/, it is probably due to the structural deficit. ERRORS DO NOT HAVE TO BE DUE TO CLEFT/VPI. 2. Determine VP adequacy: If only few high pressure consonants are used &/or attempted to be used, VP adequacy cannot be determined (either perceptually or with instrumental assessment). I will talk more about this later. 3. Determine use of Compensatory Articulations: These are articulations particular to people with cleft palate/VP inadequacy problems. More about this later. 4. Determine prognosis: look at severity of disorder, types of errors, stimulability etc.

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. You should ALWAYS watch the face/nose/mouth during articulation assessment & therapy. If you have your head down during the sounds’ productions, you will most likely miss valuable information. Nasal grimace: any extraneous movement of the nose Incorrect placement: interdental /t/, reverse labiodental /f/ Facial/Neck Tension: if need this much tension to produce sound, that is a problem. Patients may go through significant “oral motor calisthenics” to produce speech sounds. Even if it “sounds good”, if it “looks bad” that may distract the listener & impede communication.

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. Lip & Tongue Mobility &/or Restrictions: If lips barely move, bilabial sounds will be difficult. If tongue frenulum is restricted, lingua-alveolar sounds may be impacted. Dental Abnormalities: Missing teeth, unusual occlusal relationship may impact sound production. Dental appliances may interfere with sound production (braces) &/or may be ill-fitting (palatal plate) & cause interference in sound production. Respiratory Abnormalities: Weak pressure consonants may be due to poor breath support & not due to VPI/A or maybe due to both.

Guidelines: 1. Transcribe the entire production phonetically including correct productions. 2. Note if response was spontaneous or imitative. Transcribe All Productions: Allows you to obtain all errors (including vowels). Maintains/increases your phonetic transcription skills. May find it necessary to ask child to repeat production several times. Most children won’t mind especially if you tell them “my ears forgot to listen. Do your ears ever forget to listen?” (or something similar) Note Spontaneous or Imitative: Imitative increases likelihood of correct production of sounds due to hearing model. Gives an idea of expressive vocabulary skills as the more words are in imitation, probably the lower the expressive skills. This is important just by itself, but can become more important if for some reason language testing is not completed.

Guidelines cont’d.: 3. Use “narrow phonetic transcriptions” for errors not transcribable with normal phonetic symbols. Narrow Phonetic Transcriptions: Goal of detailed transcription is to note as much phonetic detail as possible. This will help in determining not only phonological patterns but errors that are likely due to velopharyngeal inadequacy. BE PREPARED TO MAKE NUMEROUS NOTES IN TRANSCRIPT AS YOU MAY SEE ERRORS SUCH AS: NAE followed by REVERSE LABIODENTAL, UNASPIRATED /f/ plus NASAL GRIMACE. BE ALERT FOR CO-ARTICULATION OF COMPENSATORY ERRORS & REGULAR SOUND PLACEMENT (/t/ plus glottal stop) Narrow phonetic transcriptions include the following (see next slide):

Other Narrow Transcriptions
Nasal Air Emission / / Denasal / / Nasalized Resonance[ ] Unaspirated [ ] Unreleased [ ] Interdental [ ] Lateralized [ ] 14. Other Narrow Transcriptions that may be needed are: a. NASAL AIR EMISSION [ ]; as in: / I/, NAE for /b/ in boy b. DENASAL [ ]; as in: / it/, denasalization of /n/ in neat c. NASALIZED RESONANCE [ ]; as in: / it/, nasalance of /i/ in eat d. UNASPIRATED [ ]; as in: /k p /, unaspirated /p/ in cup e. UNRELEASED [ ]; as in /k p /, unreleased /p/ in cup f. INTERDENTAL [ ]; as in / s I k s /, interdental placement of the tongue on /s/ in six g. LATERALIZED [ ]; as in / s a k s /, lateralization of /s/ in socks

Other Narrow Transcriptions
Transcription Symbols for Compensatory Articulation Errors EXTRA HANDOUT WILL REVIEW SHORTLY

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. Vowel Errors: Note any vowel errors. Substitutions, distortions, hypernasality etc. If you are doing a complete transcription, it will be fairly easy to note the vowel errors. Nasal Air Emissions: NAE should be counted as errors when scoring when there are more than just a few. Example of difference: 37 errors with 17 NAE difference in SS (standard score) on GFTA 2 would be 75 vs. 96. NAE ARE AN IMPORTANT COMPONENT OF ARTICULATION ERRORS IN THIS POPULATION!

Guidelines cont’d.: 6. Do stimulability testing. 7. Note any differences during conversational speech. 8. Rate the overall intelligibility/understandability of speech. Stimulability Testing: If time permits, do stimulability testing for error sounds. Do at different levels: isolation, syllable, word, phrase, sentence. Do sounds in different positions. Do with nasal occlusion to see if can make the sound then. Conversational Speech: Always be listening to conversational speech, sounds during language testing etc. Note any errors. May have differences between single word productions & conversation. Intelligibility/Understandability: Rate the overall intelligibility/understandability of speech. Be sure to include if knowing the context makes a difference. Can use a percentage or more descriptive term (good, fair, poor).

Guidelines cont’d.: 9. Note any weak pressure consonants &/or reduced intra-oral air pressure. Weak Pressure Consonants/ Reduced Intra-Oral Air Pressure: Consonant sound productions may be weak in intensity due to reduced ability to build up air pressure with the VP valve. Speech may sound muffled or indistinct.

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. Test Selection: For most patients we use the Goldman Fristoe Test of Articulation 2. Obviously, there are other choices. For infants/toddlers who cannot or will not name pictures, we conduct a Sound inventory. We observe sounds made during the evaluation & ask parents about specific consonant & vowel sounds. We have a list and give examples in words, but stress that we want to know if the child have EVER said the sound. Ex. /p/ as “puppy”, “ae” as in “hat”. We circle the sounds on the list that were heard &/or reported. Once again, the more information you have, the better the diagnosis/treatment.

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 Referred to as both “misarticulations” as well as “articulation errors”. Are an individual’s response to VP dysfunction; thus, are ACTIVE SPEECH CHARACTERISTICS. Are under the patient’s control. IMPORTANT TO NOTE AS MEANS CAN BE CHANGED WITH THERAPY. This is in contrast to PASSIVE SPEECH CHARACTERISTICS or OBLIGATORY ERRORS which occur due to the structural deficit. Ex. weak pressure consonants. Place of production changes anywhere along vocal tract to point where valving can be achieved.

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 Terms were first developed by Judith Trost-Cardamone, SLP. Were later described by Sally Peterson-Falzone, SLP. 2 BIG names in cleft palate work! Phonetic symbols have also been developed for some of these. NOTE: Not all showed up on slides, so you may have to write them on the handouts. Notice how place of articulation may occur anywhere along the vocal tract—from larynx to pharynx to velum to mid-palate TRANSCRIPTION SHEET (NOT ALL HAVE SYMBOLS) (additional handout) (HANDOUT CLAUDIA’S HANDOUT)

Types of Compensatory Misarticulations cont’d.
Atypical Backing of /l/ Atypical Backing of /n/ Atypical Backing of /r/ Novel or idiosyncratic misarticulations Novel or idiosyncratic misarticulations are particular to an individual person. These kids are very clever in making adaptations. You will most likely have to describe these. In other words,diacritic markings do not exist for them. I frequently put an asterisk at the top of my artic response form and note what it represents. Then I can just put an asterisk in the individual boxes for phonemes by position. Ex. Child produces bilabial /p/ with labiodental placement. I’M GOING TO GO THROUGH THE DESCRIPTIONS OF THE DIFFERENT COMPENSATORY MISARTICULATIONS; HOWEVER, I WILL GO THROUGH THIS INFORMATION FAIRLY RAPIDLY. I WANT YOU TO HAVE A LEAST A BASIC GRASP OF THESE TYPES OF SOUNDS.

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 1. GLOTTAL STOP / / Most well-known compensatory error Normal speech sound in many languages / dialects In English, it starts the production of vowel sounds, in isolation or when beginning a word It becomes a compensatory error when it is used as substitution for a stop consonant made in glottal place of production May also be used in substitution for any high pressure sound utilizes laryngeal (vocal cord) valving The vocal cords adduct (come together) and allow pressure to build up below the glottis

GLOTTAL STOP / / Greater pressure builds up Excessive tension
Consonant substitution > vowel initiation Excessive tension Lower vocal tract > intense opening / closing vocal cords Ventricular vocal cords adduct / contact Greater pressure builds up for consonant substitution than for vowel initiation Causes excessive tension in the lower vocal tract More intense opening/closing of the vocal cords Significant pressure may cause the ventricular (false) vocal cords to adduct and make contact at midline

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 most commonly substituted for the whole class of stops frequently produced as a coarticulated stop as in / / {as used in this context, the term co-articulation denotes an aberrant consonant production characterized by one manner of production with simultaneous valving at two places of production where the deviant, or nonphonemic place is the effective one for manner.} EX.: glottal stop + /b/ co-articulation in boy = / / perceptually distinct from pharyngeal stop or omission

Glottal Stop / / GLOTTAL STOP / /
Note point of closure is at the vocal folds (glottis).

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 11. LARYNGEAL STOP substitution for stop sounds base of tongue moves posteriorly toward the posterior pharyngeal wall epiglottis contacts posterior pharyngeal wall momentarily blocking airstream larynx thought to move superiorly, to assist in temporarily stopping the 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 / / 2. PHARYNGEAL STOP / / (unvoiced), / / (voiced) Lingua-pharyngeal consonant articulation tongue moves posteriorly to contact posterior pharyngeal wall pressure build-up below tongue-pharynx contact, followed by sudden release of air Manner of articulation = stop / plosive stop contact may occur higher or lower in the pharynx used as a substitution for /k/, /g/ not used as a co-articulation

Pharyngeal Stop PHARYNGEAL STOP / / (unvoiced), / / (voiced)
Note point of closure is tongue against posterior pharyngeal wall.

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 / / When you are saying “did I hear a /t/ or a /k/, a /d/ or a /g/” that’s when you know you’ve heard this. DEMONSTRATE: “TEA”, “KEY”, MID-DORSUM PRODUCTION

Laryngeal Fricative Substitution for fricative sounds Tongue base
Posterior Pushes epiglottis toward PPW Narrows airstream Constriction Epiglottis & PPW Larynx moves up Variant Pharyngeal fricative 12. Laryngeal Fricative substitution for fricative sounds base of tongue moves posteriorly toward posterior pharyngeal wall pushes the epiglottis toward the posterior pharyngeal wall, also this narrows the airstream to create frication point of constriction is between the epiglottis & the posterior pharyngeal wall the larynx is thought to move upward to assist in the narrowing of the airstream This may be some component or variant of the 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 / / 3. PHARYNGEAL FRICATIVE / / (unvoiced), / / (voiced) linguapharyngeal fricative articulation point of constriction is similar to pharyngeal stop, but overall lingual configuration is different: tongue moves posteriorly toward the posterior pharyngeal wall does not contact the posterior pharyngeal wall; Dorsum of the tongue is more flattened constriction of airstream causes frication substituted predominantly for sibilant fricatives and affricates; also occurs as co-articulation as in / /

Pharyngeal Fricative PHARYNGEAL FRICATIVE / / (unvoiced), / / (voiced)
Note tongue moves back toward posterior pharyngeal wall but DOES NOT make contact thus allowing for frication.

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 13. Laryngeal Affricate substitution for affricate sounds base of tongue moves posteriorly, toward the posterior pharyngeal wall causing the epiglottis to briefly contact the posterior pharyngeal wall and then constrict the airstream to create stopping and then frication the larynx is thought to move superiorly during this activity

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 / / Simultaneous glottal & lingua-pharyngeal valving:

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 POSTERIOR NASAL AFFRICATE substitution for affricate sounds posterior dorsum of tongue and soft palate are positioned to create both stopping and frication at the velopharyngeal valve always accompanied by audible nasal air emission usually occurs with the posterior nasal fricative but without other compensatory errors is often the only perceptual correlate of phone specific / sound specific nasal emission / VPI/A is amenable to speech treatment correction of tongue placement correction of oral vs. nasal 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: / / Also occurs in non-cleft speakers. NEED TO ADD SYMBOL DEMONSTRATE “LIGHT”

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: / / Also occurs in non-cleft speakers. NEED TO ADD SYMBOL DEMONSTRATE: “NIGHT”

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: / / Also occur in non-cleft speakers. NEED TO ADD SYMBOL DEMONSTRATE: “RIGHT”

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 You could have a glottal stop + attempted labiodental /b/ that is emitted nasally. (extreme example)

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 If you remember anything about compensatory misarticulations, this is it! Also, if all you can do is distinguish that there is an error and it is not a typical articulation error, that is fine. You might be able to distinguish that fricative production is backed, but you may not know if the placement is pharyngeal, laryngeal etc. It can take quite a while to “TRAIN” your ear for these type of errors & some people seem to be able to distinguish them easier than others.

Assessment-Resonance
-hypernasality -assimilative hypernasality -hyponasality -cul-de-sac -denasality -mixed resonance NOTE: RESONANCE IS SEPARATE FROM VOCAL PARAMETERS THIS IS VERY IMPORTANT IN REGARD TO VPI/A. First, go through definitions & then go through how to assess.

Assessment-Resonance cont’d. Definitions
-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 Perceptually you perceive resonance. Physically, the response to the frequency of a sound is resonance. Ex. A bell resonates after being rung.

Hypernasality: -excess nasal resonance on vowels & vocalic consonants (i.e., “ir” as in “bird”), glides (“w, y”) or liquids (“l, r”) -transcribed as: ~ Occurs because oral & nasal cavities are coupled when they shouldn’t be. Results in oral sound being produced through the nose. PLAY CHIPMUNK TAPE #11 SPEAK WITH HYPERNASALITY

Assimilative Hypernasality: -excess nasal resonance on vowels in presence of nasal consonants (“m, n, ng”) -transcribed as: ~ Same as hypernasality except oral vowels assimilate to the nasal consonants. Assimilate: become similar to or try to become like May be a timing issue. Diacritic is as same as for hypernasality. Distinguish as occurs in presence of nasal consonants. GIVE SPEECH EXAMPLE Example: “man” DEMO WITH HAND-OPEN/CLOSE FOR NASAL /M/-ORAL “AE”-NASAL /N/ Anticipatory action: may close or open too soon Subconscious action

Hyponasality: -reduction in nasal resonance -affects nasal consonants -is NOT opposite of hypernasality/can co-occur Occurs when either nasal airway is partially blocked &/or entrance to nasal passage is partially occluded. May occur with large adenoids, obstructive pharyngeal flap, deviated septum, stenotic (closed) nostril, enlarged turbinates, due to backed tongue position. PLAY CHIPMUNK TAPE #4 GIVE SPEECH EXAMPLE (occlude one nostril- “me”)

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 Picture a cul-de-sac street and you get the idea of the blind pouch with only 1 outlet. Some people describe this speech sound as “potato in the mouth” like or muffled. Large tonsils can cause as they block the entrance to the oral cavity DEMONSTRATE “GO” WITH: NORMAL PRODUCTION RETRACTED TONGUE RETRACTED TONGUE + NASAL OCCLUSION

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/ We do not hear this very often. Speech therapy will NOT correct this as it is a structural problem. Wanted to cover term/definition as it can be a component of overall resonance disorder. PRACTICE SAYING “ME”, “NO”, & “RING” WITH NOSTRILS OCCLUDED

Mixed Resonance: -combination of hypernasality, assimilative hypernasality, hyponasality, &/or cul-de-sac resonance -can have any combination -severity may vary between resonance types Hypernasality & hyponasality are NOT opposites. They are NOT at opposite ends of a spectrum. Do not occur simultaneously, but during different times in connected speech. Structural defect may cause hypernasality, but large adenoids may create hyponasality. Severity: hypernasality may be moderate while assimilative hypernasality is severe. Severity may also fluctuate or be inconsistent within each type. Fatigue, excitement, illness all seem to have the potential to negatively impact most resonance parameters as well as all parameters of speech (articulation, voice etc.)

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 scales used are subjective. Scales are usually descriptive & numerical Ex. “5”/mild As you assess more & therefore listen more, you should be able to be more accurate/precise in your judgments/ratings. CMHC uses a 7-point scale. This is true for both resonance as well as nasal air emissions (which we will discuss shortly). Previously cited CPCF Journal article of January 2008 gives ways to convert various scales.

Rating Scale cont’d.: CMHC 7-point rating scale: None Slight Mild Mild-Mod Mod Mod-Sev Severe Here is the CMHC 7-point rating scale. NOTE: “mod” refers to “moderate” “sev” refer to “severe” ALSO NOTE: Points “4” & “2” cover a range (i.e., mild-moderate, moderate- severe)

Hypernasality: Areas to Assess: Spontaneous Speech Sample Sustained Vowel Sentence Imitation task There are 3 areas to assess in regard to hypernasality. You will rate each area SEPARATELY. You will make a checkmark under the point on the rating scale for each area. SHOW CMHC PROTOCOL SHEET

Hypernasality cont’d.: Areas to Assess: Spontaneous Speech Sample Throughout assessment you should be listening to spontaneous speech & judging the overall hypernasality. You may mark this at the time you first do resonance assessment, or you may want to wait until you have heard more spontaneous speech.

Hypernasality cont’d.: Areas to Assess: Sustained Vowel /i/ Intent: to compare back-to-back productions of /i/ first WITHOUT NASAL FLUTTER, followed by WITH NASAL FLUTTER HOWEVER, YOU ARE RATING THE PRODUCTION DONE WITHOUT NASAL FLUTTER! As /i/ is an oral production, their shouldn’t be any difference in acoustics/sound. Need /i/ sustained for at least 3 seconds. Repeat sample as many times as needed.

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”. 1. Glove on hand: usually place on only 1 hand usually place on non-dominant hand -then can still write with dominant hand to gain cooperation, may need to let child wear glove(s) CAUTION: do NOT allow child to keep glove (s) due to risk of inhalation

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”. At first, I will do /i/ at the same time/simultaneously with the child Next, I want child to say /i/ alone while I slide my index finger across the table to child’s side. I STILL HAVE NOT TOUCHED THEIR NOSE!

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”. Now while child says /i/, I slide my finger across the table & I open & close their nose with my gloved hand. CAUTIONS REGARDING NASAL OCCLUSION: Child may try to do occlusion. SLP should do occluding. Then you know they are truly occluded & you can feel sounds emitted through the nose. You don’t have to occlude “tightly”, just enough to close nares. I tell the children that my rule is “I close your nose”. Nasal occlusion may cause a “runny nose”. Sometimes the “flutter” (opening & closing nostrils) acts like an “on/off” switch. You may need to repeat the directions, but with some children this step isn’t able to be accomplished.

Hypernasality cont’d.: Areas to assess: Sentence Imitation Task Once again, you’re comparing back-to-back productions with the first without nasal OCCLUSION & the second with nasal OCCLUSION. NOTE: This time you OCCLUDE the nostrils/NOT FLUTTER. JUST LIKE WITH /i/, YOU’RE RATING THE UNOCCLUDED PRODUCTION! Also, like /i/, ALL OF THE WORDS IN THE STIMULUS SENTENCES ARE PRODUCED ORALLY. THEREFORE, THERE SHOULDN’T BE A DIFFERENCE IN ACOUSTICS/SOUND OF THE OCCLUDED/NON-OCCLUDED SENTENCES. Again, repeat sample as needed. Again, put a check mark under the perceived severity level.

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.” You want the 2 productions of each sentence to occur in fairly rapid succession. One right after the other. This makes it easier to compare the 2 productions as your brain will better retain the acoustics/sound. The more time between imitated productions, the less accurate will be your severity ratings. NOTE: /i/ is used in most of these sentences as well as for the sustained vowel production & in the sentences used to assess assimilative hypernasality. /i/ is used because it is a HIGH FRONT VOWEL (location of tongue during production) & can be one of the, if not the, hardest vowel for those with VPI/A to maintain oral resonance during it’s production. Tongue is “taking up space” in oral cavity. Air/sound will go “path of least resistance”. With VPI/A, that will be nasally. In other words, we’re trying to TASK THE SYSTEM If we were to use say /a/ (a low front vowel), the results may be different.

Hypernasality cont’d.: Sentence Imitation Task cont’d. CAUTIONS: Some children (in particular boys from around 6-10 years of age) will discover they can force the sounds/productions through their nose. By being the one to provide the occlusion, you should not only hear this, but you will ALSO FEEL it. They truly enjoy doing this. You may have to tell them “you made that in your nose, I want you to keep it in your mouth”. I frequently touch their nose & point to their mouth when I say this. If this happens, you will need to repeat the testing. Some productions fluctuate in the amount/severity of hypernasality. Fluctuations can occur within a sentence as well as across sentences. For example, the beginning of the sentence may be perceived as moderate hypernasality, while the end of the sentence may be slight or none. You should make note of these fluctuations on your protocol sheet. This is all pertinent information for making your diagnosis. On the sentence “put your feet by the seat”, some children will literally do that action. That’s ok. Just make sure they also say the sentence.

Assimilative Hypernasality: Area to assess: Sentence Imitation Task Now remembering the definition of assimilative hypernasality, we’re now testing for hypernasality on vowels in the PRESENCE OF NASAL CONSONANTS. Therefore, we WILL NOT USE NASAL OCCLUSION! Some people do not have any trouble with non-nasal contexts, BUT HAVE TROUBLE ONCE VOWELS ARE PUT IN A NASAL CONTEXT. In other words, this MAY BE MORE TASKING TO THE VP SYSTEM. Words such as “mean” require rapid VP valve movement. In “mean”, the valve is open for /m/, closed for /i/, & opens again for /n/. DEMONSTRATE WITH HANDS Some people have trouble with the timing of the opening & closing of the VP valve. They may keep the valve open after /m/ thus making /i/ nasal &/or they may open the valve too soon (during production of /i/) in anticipation of /n/. Once again, this would make /i/ nasal.

Assimilative Hypernasality cont’d.: Area to Assess: Sentence Imitation Task cont’d. Again, repeat sample as needed. Again, put a check mark under the perceived severity level. .

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”. Once again, severity may fluctuate within &/or across sentences. CAUTIONS: I usually follow up the “mean dog some meat” sentence with “would you even get close to a mean dog? I would leave it alone.”

Hyponasality: Areas to Assess: Sustained nasal /m/ Sentence Imitation Task Now remembering the definition of hyponasality, we’re now listening for not enough nasality on nasal consonants. Once again, we WILL NOT USE NASAL OCCLUSION! Again, repeat sample as needed. Again, put a check mark under the perceived severity level. In regard to assessment of sustained nasal /m/: I don’t always repeat /m/ as have already listened to during nasal patency testing. I’ll mark severity from that. BUT if I’m unsure, I will go ahead & test. I want the /m/ sustained for 3 seconds.

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”. Once again, severity may fluctuate within &/or across sentences.

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 Cul-de-sac, Denasality, Mixed Resonance We do not use specific stimuli for these areas as we use for the other resonance areas. You should be perceptually rating/making judgments regarding these areas while you are assessing other resonance areas, articulation & during conversational speech, You should make notes regarding your judgments etc. In regard to MIXED RESONANCE, you should have an idea about this based on assessment for hypernasality, assimilative hypernasality & hyponasality.

Infant-Toddler Assessment: 1. SLP rates severity of overall hypernasality in spontaneous speech. 2. SLP rates severity of overall hyponasality in 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? Most infants & toddlers will NOT let you assess resonance (hypernasality, hyponasality) as you would do with older kids. SLP can use 7-point scale to rate overall hypernasality & hyponasality in spontaneous speech. SLP can note if COULD NOT TEST (CNT). You may not hear any spontaneous speech or very little. SLP can ask parents to rate overall hypernasality & hyponasality on 7-point scale. SLP can ask parents if they’ve perceived any CHANGES in resonance. If they say “yes”, SLP should ask when & how (description). REMEMBER, THOUGH, MANY PARENTS HAVE DIFFICULTY WITH THE HYPER & HYPONASALITY CONCEPTS & WILL EITHER GIVE INACCURATE INFORMATION &/OR STATE THEY DON’T NOTICE EITHER OF THESE. PARENTS FREQUENTLY CONFUSE RESONANCE WITH PITCH LEVEL.

Assessment-Nasal Air Emissions (NAE)
-audible -inaudible -nasal grimace -nasal turbulence/rustle Once again, these may all occur or only some may occur. Severity can differ within types and between types. Severity may fluctuate over time or across sounds or stimuli (isolation, syllable, word, sentence, conversation). So now let’s go over the definitions.

Assessment-NAE cont’d.
Audible Nasal Air Emissions: -oral consonants produced (emitted) through the nose -airstream is heard from the nose -transcribed as: ~ Severity may vary. May be ok at isolated sound or syllable level, but have difficulty in sentences. NEED TO ADD DOT ABOVE & BELOW DIACRITIC MARK GIVE SPEECH EXAMPLE

Inaudible Nasal Air Emissions: -oral consonants produced through the nose -not heard perceptually -detected by mirror exam May have inaudible NAE on sounds, but not audible. Can also sometimes occur vice versa. Presence of fogging on mirror (inaudible NAE) indicates VP inadequacy. DEMONSTRATE ON MIRROR

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 Have to be looking at patient (straight on/face-to-face) while saying stimuli to observe. I note this with NG & try to describe the grimace (i.e., slight bilateral nostril flaring). You could develop your own code or symbol to record this. Just make sure you also describe it. GIVE SPEECH EXAMPLE

Nasal Turbulence/Rustle: (NT) -oral consonant sound occurs during partially opened velopharyngeal valve -air flow is turbulent with noted noise/rustle Air flow “rustles” through the nose. May hear more when congestion/drainage (upper respiratory infection, cold, allergies) is present. Will hear it “rattle”. May only occur on certain consonant sounds. More likely to occur more on those sounds that require more pressure. I note this with NT. Once again, you could develop your own code or symbol to record this.

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 Intent: TO ASSESS HIGH PRESSURE CONSONANTS ACROSS CONTEXTS TO SEE IF & WHEN VP MECHANISM BREAKDOWN OCCURS THE GREATER REQUIREMENT FOR PRESSURE, THE MORE LIKELY A BREAKDOWN WILL HAPPEN There are several areas to assess in regard to nasal air emissions. Some of the areas will be assessed for both audible & inaudible nasal air emissions, BUT NOT ALL AREAS. For example, when assessing mixed nasal/oral loaded words you would not assess for inaudible NAEs (mirror test) as you would expect mirror to fog due to presence of nasal consonants. The 7-point severity scale is used to rate all areas EXCEPT conversational speech, single high pressure consonant words (IPAT) & stimulability for correction. For the areas where both audible & inaudible NAEs are assessed, they will be rated separately. SHOW CMHC PROTOCOL SHEET

Area to Assess: Isolation Intent: Assess high pressure consonants /s/, /p/, /t/, /k/ & “sh” in isolation both with & without the mirror Rate severity of audible & inaudible NAEs Note any nasal turbulence/rustle Note any nasal grimace & try to describe (ex. bilateral nostril flaring, scrunching at mid-portion of nose) Rate each phoneme separately: if all are the same severity, make checkmark if are different severities, put phonetic symbol under rating area sometimes several sounds will cluster at 1 point on the scale & 1 or 2 will be at other points Make note if mirror fogs from left, right or both nostrils DON’T WAIT TO MARK RATINGS. MARK AS YOU DO EACH SOUND ETC.! THERE IS A LOT TO LISTEN TO/PAY ATTENTION TO/DON’T TRUST YOUR MEMORY!

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/”. Intent: to have sound imitated in isolation WITHOUT vowel

Isolation cont’d.: 5. “Say /p/”. 6. “Say /t/”. 7. “Say /k/”. 8. “Say “sh”. You may not be able to assess all sounds. If learned from articulation testing that child cannot produce a sound, you won’t be able to test it. Ex. If child always fronts /k/ & produces /t/, you can’t test /k/.

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). Tips for Using the Mirror: Some children will pull their head back away from the mirror. You may need to tell them “don’t pull your head back &/or you may need to stabilize their head with your hand either gently on the top of the their head or behind it. 2. Many children bend down & try to see their image in the mirror. Once again, you may need to tell them “don’t bend down” &/or you may need to stabilize their head with your hand either gently underneath their chin or on their forehead. You may also let them have a chance to see themselves in the mirror either before or after testing. There is a timing to placing the mirror under the nostril(s) so that you don’t “catch” when they are exhaling/breathing out. With PRACTICE, you will improve. 4. You can test both nostrils, but if one was completely occluded during the nasal patency test THERE IS NO REASON TO DO THE MIRROR TEST UNDER THAT NOSTRIL.

Area to Assess: CV Syllables Intent: Assess high pressure consonants /s/, /p/, /t/, /k/ & “sh” in consonant-vowel syllable with vowel /a/ (“ah”) both with & without the mirror. Same rating rules/procedures apply as at the isolation level. Rate severity of audible & inaudible NAEs Note any nasal turbulence/rustle Note any nasal grimace & try to describe Rate each phoneme separately: if all are the same severity, make checkmark if are different severities, put phonetic symbol under rating area sometimes several sounds will cluster at 1 point on the scale & 1 or 2 will be at other points Make note if mirror fogs from left, right or both nostrils.

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/”.

CV Syllables cont’d.: 5. “Say /pa/”. 6. “Say /ta/”. 7. “Say /ka/”. 8. “Say “sha”. Once again , depending on articulation errors you may not be able to assess all sounds.

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 Intent: Assess high pressure consonants in phoneme-loaded sentences both with & without the mirror. Phoneme-Loaded Sentences: Sentences will have the target phoneme repeated several times. If child can’t repeat whole sentence, then “go for the meat of the matter”. In other words, shorten the sentence to the words with the targeted phoneme, but make notation that used abbreviated stimuli. We’re trying to task the VP system with not only need for increased pressure due to sounds, but also due to length of utterance. NOW with the high pressure consonants we will be working through the continuum of need for pressure from low (plosives) to medium (fricatives) to high (affricates).

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”. Sometimes I tell the kids that the sentences are funny or they are tongue twisters. I will also ask younger kids if they know what a sentence is & then I will usually say “it’s when we put several words together to say something”. Notice how the phoneme /p/ repeats in the sentence. If I were to reduce/abbreviate this sentence, I might say “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’.” Notice that the sentences are presented in pairs of cognates-first the voiceless, followed by the voiced. Also notice, that most sentences have the target phoneme in all positions (IMF) in words. FYI—The sentence regarding “daddy” & the “dishes” frequently is accompanied by laughter (by child, mom, &/or dad).

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’.” The tendency may be for the child to either produce high pressure consonants weakly or to omit them. You may need to over-emphasize the target phoneme as well as encourage the child to “use all of your sounds” or “put all your sounds on”. This seems to happen frequently on the medial & final sounds (ex. “iCicleS”) You will need to be aware of the rate/speed at which you present the sentences”. DON’T TRY TO GO TO FAST (which is easy to do after this sentences become ROTE for you). Note that the sentence “Thank you for the birthday present” includes NASAL CONSONANTS in the 1st & last words. The mirror should fog on those.

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). NOTE: You will present all of the plosive sentences BOTH with & without the mirror BEFORE doing the same for the fricative & affricate sentences. This breaks it up some and seems to be easier for most kids; however, with older patients who could probably do all the sentences without the mirror followed by with the mirror.

Area to Assess: Mixed Nasal/Oral Loaded Words & Sentence(s) Intent: Assess ability to rapidly open & close the VP port while maintaining oral & nasal sounds Same rating rules/procedures apply as at previous levels EXCEPT ONLY RATING FOR AUDIBLE NASAL AIR EMISSIONS. In other words, you will NOT test with the mirror due to the presence of nasal consonants. You’re listening to see if oral plosives remain oral or if they are produced nasally due to difficulty rapidly opening & closing the VP port. Rate the severity of audible NAEs Note any nasal turbulence/rustle Note any nasal grimace & try to describe

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.” “Hamper” & “Donna” test at the word level. The last sentence (“Thank you for the birthday present.”) tested at the sentence level.

Area to Assess: Conversational Speech Intent: Assess high pressure consonants during conversational speech For the most part, this is similar to what has been done at the isolation, syllable & phoneme-loaded sentence levels. Rate severity of audible NAEs. Do NOT rate inaudible NAEs as it is difficult to hold the mirror under the nostrils throughout conversational speech & as that may interfere with “NATURALNESS” of conversational speech. Note any nasal turbulence/rustle. Note any nasal grimace & try to describe.

Conversational Speech: Areas to Rate/Observe in regard to NAEs: Present vs. Absent Pervasive vs. Inconsistent vs. Occasional Nasal Turbulence Nasal Grimacing REMEMBER NAE REFERS TO BOTH AUDIBLE & INAUDIBLE NASAL AIR EMISSIONS! Present vs. Absent (none): check if NAEs have been heard/seen or not Pervasive vs. Inconsistent vs. Occasional: Pervasive: NAEs occur on most high pressure consonants & across most contexts Inconsistent: NAEs occur fairly frequently on one or more sounds, but not always Occasional: NAEs only occur every now & then Nasal Grimacing & Turbulence: what we have already covered/discussed

Area to Assess: Single High Pressure Consonant Words Intent: Assess numerous high pressure consonants in imitative single word productions Rate severity of audible NAEs. Can check for inaudible NAEs with mirror if unsure regarding occurrence of audible NAEs. BUT USUALLY DO NOT DO MIRROR TEST Note any nasal turbulence/rustle Note any nasal grimace & try to describe

Area to Assess: Single High Pressure Consonant Words cont’d. Stimuli: Iowa Pressure Articulation Test (IPAT) Iowa Pressure Articulation Test (IPAT): (This is part of the Templin-Darley Tests of Articulation, 1960) SPECIFICALLY DESIGNED TO ASSESS EFFECTS OF VPI IPAT has 43 stimuli that target high pressure consonants in imitated words. Scoring: Only count NAEs (or NG or NT) on TARGETTED SOUNDS in total # wrong BUT should also note NAE/NG/NT on non-target sounds CANNOT test items with ARTICULATION ERRORS BUT should note articulation errors as serves as double check against articulation test & gives idea of stimulability in imitative words (ex. can test stimulability for initial /s/ blends by demonstrating index finger tracing down arm during production) Can determine percent NAE BUT only count # stimuli given (ex. If do not do 5 words due to artic errors, total stimuli would be 38 instead of 43) Rate severity of NAEs/NG/NT May want to compare # of NAE vs. NG vs. NT

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 _____ 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 _____ Stimuli are listed by single items (sounds), 2-item blends & 3-item blends Within each listing, the stimuli are grouped by normal age of acquisition As age of acquisition is NOT pertinent to the scoring, I have omitted it.

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. Continue through all of the stimulus words. Make a checkmark for NAE on targeted sound. Note NG (& describe). Note NT. Make a vertical line if no NAE/NG/NT. Note articulation errors by writing substitutions above phoneme, crossing out omissions. Kids frequently pay attention to list so you want to mark each line. May want to put a star at last line & tell them “you’ll be done with this page when you get to the star”. As the IPAT is fairly easy to administer we will NOT PRACTICE with it.

Area to Assess: Stimulability for Correction You have actually been doing this throughout assessment as you have provided imitative stimuli. You can take this another step further by occluding the nose (gloved hand) to see if can move NAEs to oral productions. You can also see if a cue such as “you used a nose sound, now make it a mouth sound” is helpful in moving NAEs to oral productions.

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 When you’re done with all the different contextual levels for assessing NAEs, you will want to do an OVERALL RATING. The areas are like what has been previously described. You’re just thinking “what is the BIG PICTURE” in regard to NAEs.

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). You will NOT be able to administer the various NAE assessments (isolation, syllables) with most infants or toddlers. You can perform an overall rating of nasal air emissions just like the summary for older kids. You can also note if stimulable for correction. Some infants-toddlers will let you occlude the nose, BUT not many. Some infants-toddlers will respond to the cues to “make a mouth sound, not a nose sound” etc. Could Not Test = child was not cooperative/child lacked phonemes/vocalizations Did Not Test = you didn’t attempt to test

Assessment-Velopharyngeal Adequacy (VPA) Procedure
Intent: To PERCEPTUALLY determine VP adequacy Now that you have ALL the information from assessing RESONANCE, NASAL AIR EMISSIONS, & ARTICULATION skills you need to make a PERCEPTUAL JUDGMENT regarding VP adequacy. The KEY WORD here is PERCEPTUAL (hearing). The other KEY WORD is ADEQUACY (umbrella term). Remember the VP VIN diagram. HOLD UP VIN DIAGRAM You’re NOT trying to determine the CAUSE FOR VP INADEQUACY you’re trying to use your ear to DETERMINE IF IT EXISTS!!!

Assessment-Velopharyngeal Adequacy (VPA) cont’d. Procedure
VP Ratings: Velopharyngeally Adequate (VP/A) or Velopharyngeally Inadequate (VPI/A) 2 broadest categories would be YES the child is VP adequate NO the child is VP inadequate VP adequate: there have been no or very minimal: resonance issues (hypernasality, hyponasality, denasality, cul-de-sac) nasal air emissions (audible, inaudible, grimace, turbulence) weak pressure consonants /reduced intra-oral air pressure VP inadequate: there have been some or significant: nasal air emissions/nasal grimace/nasal turbulence weak pressure consonants/reduced intra-oral air pressure NOTE: MAY ONLY HAVE PROBLEM IN 1 AREA, BUT IF SIGINICANT ENOUGH IS VPI/A!!!!!

VP Ratings cont’d: Other possibilities: Borderline VPI/A Questionable Borderline VPI/A: symptoms (whether resonance, NAEs, weak pressure &/or combination) are present & consistent enough to be VPI, but are so SLIGHT they DON’T HAVE A SIGNIFICANT EFFECT on OVERALL INTELLIGIBILITY This gets back to the definition of a communication disorder. If the listener is NOT SIGNIFICANTLY impacted, then is it a disorder/problem? Questionable VPI/A: symptoms suggest VPI, but inconsistent enough to truly call it VPI/A (may be related to function) Difference Between Borderline & Questionable: Borderline: I hear slight hypernasality & see slight inaudible NAE on mirror exam. Doesn’t interfere with my ability to understand the person. Questionable: I hear mild or greater hypernasality occasionally & sometimes hear mild or greater NAE on high pressure fricatives. Not consistent enough to call VPI/A.

VP Ratings cont’d.: Other Possibilities cont’d.: Unable to determine at this time Could not test Unable to Determine at This Time: insufficient information to make a perceptual judgment; may have too many articulation errors &/or compensatory articulation errors to determine adequacy (lack of proper sample) Just don’t have enough results to determine. Could not test: may have been too young to do/complete testing; may have fatigued/not cooperated for any or some of testing As most children do not distinguish oral vs. nasal sounds until around the age of 2, it is hard to determine if 2 year old is using hypernasality due to VPI/A or due to developmental reasons. FREQUENTLY WE CANNOT PERCEPTUALLY DETERMINE VP ADEQUACY UNTIL AROUND 4- 5 YEARS OF AGE. THIS IS DUE TO ARTICULATION ERRORS, TIMELINE FOR ACQUISITION OF HIGH PRESSURE FRICATIVES/AFFRICATES/WILLINGNESS TO COOPERATE FOR ASSESSMENT etc.

Assessment-Language Procedure
Intent: to determine if language skills are age-appropriate As language disorders are a frequent component of the overall communication disorder of patients with cleft lip &/or palate you will want to evaluate language skills. You should evaluate both RECEPTIVE and EXPRESSIVE language skills, if at all possible. Reasons for this include: late acquisition of sounds (due to time of palate repair) THEREFORE possible late acquisition of words higher incidence of ear infections/at least temporary hearing loss if not hearing loss (due to overall anatomy changes from cleft) higher incidence of cleft lip &/or palate being part of a syndrome which includes language &/or learning difficulties limited language stimulation for children abandoned at birth (due to CLP) & placed in orphanages (particularly true for Asian population)

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) Assess receptive & expressive skills: -try to establish skill level in both areas -try to determine if a significant gap exists between receptive & expressive skills -try to determine if language skills are commensurate with (match) cognitive skills Choose an age/developmentally-appropriate test: -for children under 3: most likely a parent report instrument (i.e., REEL-3, The Rossetti Infant-Toddler Language Scale, MacArthur Communicative Development Inventory) (CMHC tends to use REEL-3 or MacArthur) - for children 3-6: tests administered directly to child (i.e., PLS-4, Celf-P-2) (CMHC tends to use PLS-4) -for children 6 & above: tests administered directly to child (i.e., Celf-4, ROWPVT, EOWPVT) (CMHC tends to use Celf-4)

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 At CMHC we prioritize ARTICULATION, RESONANCE, NASAL AIR EMISSION, PERCEPTUAL DETERMINATION OF VP ADEQUACY & ORAL MECHANISM EXAM OVER LANGAUGE Reasons being: most referring/outside SLPs are seeking this detailed/expert information AND most referring/outside SLPs have a greater amount of experience with language assessment than with assessment as it relates to artic/VPI in those with clefts SO if we have to, we may NOT TEST LANGUAGE BUT If language test results have been unavailable for a number of years we will try our best to assess language (either on a same day appointment or follow-up appointment).

Assessment-Voice Procedure
Intent: to assess voice for abnormalities in pitch, volume, &/or quality Patients with CLP MAY OR MAY NOT have problems with the various vocal parameters. You want to RATE THESE AREAS AS ADEQUATE OR DEVIANT. You want to be able to DESCRIBE THE PATIENT’S VOCAL PARAMETERS. You will rate these areas during other assessments &/or conversational speech. There are a LOT OF THINGS TO LISTEN FOR SIMULTANEOUSLY. (artic, resonance, NAE, voice, fluency, language etc.) This will get easier with practice. With infants/toddlers there is usually limited expressive speech to judge these areas.

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 You will FREQUENTLY HEAR vocal HOARSENESS in these patients as VPI/A can lead to vocal cord nodules. Patients try to valve anywhere they can along the vocal tract when they have trouble with VP valving. They may hyperfunction at the level of the vocal cords which can cause vocal nodules which can cause a hoarse vocal quality due to irregular shape/mass of cords/inflammation. Aphonic: absence of voice May want to ask additional history questions regarding vocal usage (screaming, car noises during play), hydration, allergies, reflux, asthma etc. Are these symptoms chronic or acute? If hear any UNUSUAL CHARACTERISTICS will want to refer for endoscopy to visualize the cords in order to evaluate their structure & function. This is VERY IMPORTANT to RULE OUT PHYSICAL/PATHOLOGICAL PROBLEMS.

Assessment-Fluency Procedure
Intent: to assess if speech is fluent or dysfluent Once again, this is done during other testing. It is a screening in regard to fluency. If dysfluencies are noted, will probably want to do more in-depth assessment at another time. The incidence of stuttering is NOT HIGHER in those with CLP than the general population.

Assessment-Oral Mechanism/Oral Peripheral Examination Procedure
Intent: to assess oral mechanism for structure & function deficits Terminology: At CMHC we typically refer to this as an ORAL MECHANISM EXAMINATION, however, the term ORAL PERIPHERAL EXAMINATION may be preferred as it is more inclusive. ORAL PERIPHERAL includes the oral mechanism BUT it also includes the periphery (or area around the mouth). You SHOULD be making observations regarding the nose, eyes, ears, hairline, midface, fingers, shape of the skull, etc.. Tomorrow there is a presentation by Alice Kahn, Ph.D., Associate Professor, Miami University, Oxford, Ohio regarding craniofacial anomalies. She will cover several common anomalies of the eyes, ears and face and how they relate to communication disorders. This would be a very beneficial presentation & would probably cover these areas more in-depth than I am doing. Dr. Kahn’s presentation is 2 parts with Part 1 at 8:30-10:00 & Part 2 at 10:30 to 12:00. Part 2 looks in-depth at Waardenburg syndrome.

Selection of Protocol: formal or informal
Assessment-Oral Mechanism/Oral Peripheral Examination cont’d. Procedure Selection of Protocol: formal or informal Protocol Selection: Over the years, some formal assessments have been available. You may want to use one of these OR You may use an informal checklist such as we use at Children’s Mercy. Either way you want a form that is easy to mark (able to circle or check items observed). Also, the more items written on the form, the more it will remind you what to assess/observe. You will want to be SYSTEMATIC in your assessment. If you follow a routine, you will be less likely to overlook something. My preference is to look first at an anatomical structure & then assess/observe it’s function. For example, I will look at the lips & note symmetry, scaring etc. & then I will assess function (protrusion, retraction).

Positioning of Patient: eye level at level of oral cavity
Assessment-Oral Mechanism/Oral Peripheral Examination cont’d. Procedure Positioning of Patient: eye level at level of oral cavity seated, erect You want the patient seated upright & erect during the examination. Your eye level should be at the level of the patient’s oral cavity. You may have to alter seating arrangements: change height of chairs, sit on the floor while child is seated etc. This positioning works for most patient’s as long as they are cooperative. For younger patients (infants/toddlers), it works best to have them supine on the caregiver’s lap with the head in the bend of the caregiver’s elbow. The mouth should fall open affording a view. However, the tongue may drop back into the pharynx obscuring the view. A tongue blade/depressor could then be used. Sometimes younger patients REFUSE TO OPEN their mouths. Some techniques to assist in mouth opening include: placing tongue blade firmly between upper & lower incisors & apply steady pressure OR occluding the nose to force mouth open for breathing. I prefer the later.

Initial Observations: Note if cleft exists & type
Assessment-Oral Mechanism/Oral Peripheral Examination cont’d. Procedure Initial Observations: Note if cleft exists & type (none, overt, submucous) PRIOR to assessing individual structures you will want to make overall observations. First, note if a cleft exists or not by marking one of 3 choices: -none (may have craniofacial anomaly, but not a cleft) -overt (cleft is visible, able to be seen) -submucous (either see some of the classic symptoms of &/or has previously been diagnosed)

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 REMEMBER you can have various combinations (i.e., unilateral left cleft lip with bilateral cleft palate; unilateral right cleft lip with submucous cleft palate). A MIDLINE cleft is just what it says: the cleft is down the midline or middle of the lip &/or palate. Often associated with other midline anomalies (i.e., bifid nose, hypertelorism-wide spaced eyes, brain anomalies). A FACIAL cleft generally affects more of the nose/cheek &/or other soft tissue facial structures as well as skeletal structures. Midline cleft is one type of facial cleft as is OBLIQUE CLEFT (cleft begins at mouth & then goes laterally, horizontally & upward thus affecting facial bones, nasal structure, orbits, maybe the ears). FACIAL clefts are extremely disfiguring.

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 REMEMBER the classic triad for submucous cleft palate is: BIFID UVULA (split) NOTCH IN HARD PALATE (at juncture of hard & soft palates) (would need to palpate to detect) MUSCULAR DIASTASIS (zone pellucida, bluish midline) (occurs where muscles of palate are oriented in the wrong direction, from front to back instead of across) DEMONSTRATE WITH FINGERS BUT REMEMBER YOU DON’T HAVE TO HAVE ALL OF THESE SIGNS OR EVEN ANY TO HAVE A SUBMUCOUS CLEFT PALATE!!!!!

Mandible/Maxilla Alveolus Hard Palate Soft Palate Other
Assessment-Oral Mechanism/Oral Peripheral Examination cont’d. Procedure Structures Assessed: Lips Tongue Nose Teeth Mandible/Maxilla Alveolus Hard Palate Soft Palate Other Now that you’ve made your PRELIMINARY OBSERVATIONS, you are ready to assess individual structures. These are the MINIMAL STRUCTURES you would assess/observe.

Functions Assessed: Lip Movements Tongue Movements Soft Palate Movement

Structures Assessed: Lips Assess/Observe: Symmetry scarring thinness/thickness continuity of muscle notching limited mobility/tight frenulum protruding premaxilla open resting posture lip pits SYMMETRY: Note if both halves of the cleft lip are symmetrical (equal in size & shape) or if they are asymmetrical. Note it is not unusual to have asymmetry after lip repair. SCARRING: may note scarring on lip at site of repair/ scarring may extend to nostril THINNESS/THICKNESS: upper lip may be abnormally thin; Cupid’s bow was be flat or non-existent CONTINUITY OF MUSCLE: it may appear that muscle is not connected across length of lip; muscle may BULGE with lip either at rest or during protrusion. NOTCHING: notch may occur at site of repair; may extend into vermillion border ALSO may be form fruste or microform (partial or arrested form of cleft lip)

Functions Assessed: Lips Assess/Observe: protrusion retraction
Assessment-Oral Mechanism/Oral Peripheral Examination cont’d. Procedure Functions Assessed: Lips Assess/Observe: protrusion retraction approximation PROTRUSION: to assess protrusion ask the patient to say “oo” (as in “too”) & demonstrate as you ask them. Observe can the lips protrude? Is it symmetrical? Is protrusion limited? RETRACTION: to assess retraction ask the patient to say “ee’ (as in “tee”) & demonstrate as you ask them Observe can the lips retract? Is it symmetrical? Is retraction limited? APPROXIMATION: note if the patient is able or not able to put their lips together. To assess ask the patient to “put your lips together” & demonstrate as you ask them. Can also have them repeatedly say /p,b/ Observe can the lips approximate (touch)? Is it for the length of the lips? With all of these assessments, use of a mirror for the patient to observe your demonstration as well as watch their own response is helpful.

Structures Assessed: Tongue Assess/Observe: size shape scarring
Assessment-Oral Mechanism/Oral Peripheral Examination cont’d. Procedure Structures Assessed: Tongue Assess/Observe: size shape scarring lingual frenulum SIZE: note if the tongue appears to be either too small (microglossia) or too large (macroglossia); compare the size to the mandibular arch, the palatal arch, & the overall space of the oral cavity. Observe if tongue DOESN’T FIT when teeth are closed. Large tongue can affect dentition. Infant’s tongue is larger compared to cavity. Tongue achieves maximum size around CA: 8, but mandible will grow for several more years. SHAPE: notice overall shape of tongue (oval blade, narrowed, pointed etc.) SCARRING: notice if tongue has any scars which might impact movement for articulation (scars may occur from use of tongue flap to repair oronasal fistula)

Functions Assessed: Tongue Assess/Observe: protrusion depression lateralization elevation-outside oral cavity elevation-inside oral cavity circling lips clicking On ALL OF THESE you will need to look for/note: imprecise movements, groping movements, lip assist, jaw assist, head extension & ANY OTHER EXTRANEOUS MOVEMENTS. This includes physically moving their tongue with their fingers! **By NOTE I mean WRITE DOWN YOUR OBSERVATIONS! PROTRUSION: to assess protrusion ask the patient to “stick out your tongue” & demonstrate as you ask them. You may also have to tell them “you won’t get in trouble for sticking your tongue out”. Observe if they can protrude their tongue independently OR if it rests on their lower lip OR is stabilized between their lips or teeth. Note how far it can protrude. Is it past their lower lip, resting on the lower lip, only to the inside edge of the lower lip? Do they have to LEAN forward or extend their neck forward?

Structures Assessed: Nose Assess/Observe: size/width shape nostrils (opening & nasal alae) tip nasal bridge columella septum scarring symmetry SIZE/WIDTH: note if the nose appears either too small or too large note if the width is narrow or wide note if the nose appears long A long nose is frequently seen in 22q deletion. SHAPE: note the overall shape of the nose NOSTRILS: note the size & symmetry of the nares (nasal openings) In unilateral cleft lip frequently one nostril is larger (usually the non-affected side) note if the nasal alae (wings of the nostrils/flaring of cartilage to form outer sides of nostrils) are flattened The nasal alae are frequently flattened when there is an unrepaired alveolar cleft as the alae rest on the bone for support, thus giving them a base for their shape.

Functions Assessed: Nose Assess/Observe: patency obstruction
Assessment-Oral Mechanism/Oral Peripheral Examination cont’d. Procedure Functions Assessed: Nose Assess/Observe: patency obstruction You should have already determined PATENCY when you did the mirror test. OBSTRUCTION: note any obstruction in the nares/nostrils Note any congestion. Observe if the patient is a nasal breather or mouth breather. Do KEEP IN MIND there may be other causes for mouth breathing (enlarged tonsils, enlarged adenoids). A number of nasal structure deficits can cause or contribute to nasal obstruction. (flattened alae, short columella, flattened nasal bridge, narrow nostril opening(s), deviated septum). Upper airway obstruction is fairly common with cleft palate or craniofacial anomalies.

Structures Assessed: Teeth Assess/Observe: occlusal relationship incisor relationship supernumerary teeth rotated teeth missing teeth crowding primary/permanent condition (cavities) appliances In order to evaluate the teeth it is important to know about normal dentition. This would include the number & type of teeth for both primary (deciduous) & permanent (succedaneous, secondary) teeth as well as approximate age of tooth eruption. MENTION EXTRA HANDOUTS It is also important to know about dental occlusal relationships. A common classification system that is widely used is the Angle Classification System which was first described by Dr. Edward Angle in the 1890’s.

Functions Assessed: Teeth
Assessment-Oral Mechanism/Oral Peripheral Examination cont’d. Procedure Functions Assessed: Teeth There ISN’T necessarily DIRECT observations regarding FUNCTIONS of the teeth BUT by OBSERVING their structure, occlusal relationships etc. you can make some PREDICTIONS regarding their functions, including: Articulation Chewing Support for facial structures (i.e., cheeks)/affect on profile/mid-face & therefore resonance/ airway.

How to Assess Teeth: Tell the patient to “open your mouth, close your mouth” & demonstrate as you ask them. This will usually put the teeth in their normal occlusal relationship BUT Sometimes this doesn’t work. The patient may thrust their lower jaw forward or place their teeth edge-to-edge. IF that happens, tell the patient to “bite down on your back teeth”. This will put the molars in relationship. THEN you insert a tongue depressor between the side teeth & cheeks (check both sides) to view the occlusal relationship.

Structures Assessed: Mandible/Maxilla Assess/Observe: micrognathia
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 MANDIBLE: lower jaw MAXILLA: upper jaw During examination of the teeth, you have PROBABLY already made some observations regarding the mandible & maxilla. MICROGNATHIA: small or hypoplastic mandible may affect articulation ( if retruded enough may NOT be able to approximate lips) OR airway -frequently seen in Pierre Robin sequence MACROGNATHIA: abnormally large or elongated jaw may affect articulation ( if protruded enough may NOT be able to approximate lips)

Structures Assessed: Alveolus Assess/Observe: residual cleft fistula
Assessment-Oral Mechanism/Oral Peripheral Examination cont’d. Procedure Structures Assessed: Alveolus Assess/Observe: residual cleft fistula ALVEOLUS: alveolar (maxillary) gum ridge RESIDUAL CLEFT: note if there is still a cleft at the cleft site (unilateral or bilateral) FISTULA: a fistula is an abnormal hole or opening from one body cavity to another (i.e., palatal fistula goes from oral cavity to nasal cavity) Note if there is a fistula in the alveolus, a NASOLABIAL fistula. It appears just under the upper lip & in the line of the cleft. It may have been purposely left at time of primary repair in anticipation of later bone graft (usually around 6-8 years of age). HOWEVER sometimes the mucosa has been repaired PRIOR to bone graft. Nasolabial fistula do NOT usually affect speech (not area of articulation & do not reduce intraoral air pressure). Technique: use a tongue depressor or dental mirror to gently raise the upper lip. It may also be palpated by a gloved hand.

Structured Assessed: Hard Palate Assess/Observe: repaired vs. unrepaired width shape/height of palatal vault scarring/fissures/protuberance surgical alterations fistula palpated notch coloring REPAIRED VS. UNREPAIRED: You should have already noted this during your initial observations regarding the oral mechanism, but if you didn’t get a look or good look in the mouth, you should observe this now. WIDTH: note if the palatal is fairly broad or if it is narrow If the palate is narrow there should be a corresponding narrowed maxillary arch. A broad palate without a narrowed maxillary arch is needed for articulation of sounds where the tongue needs to fit within the arch (lingua-alveolars /t, d, n, l, s, z,/ “ch” & “j” or touch the palate (lingua-palatals “sh” & “zh” as in beige” & /r/). A narrow palate may be due to the type of repair, amount of tissue available for repair, or other causes.

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 The soft palate INCLUDES the velum (soft palate) & the uvula (“hangy down part/punching bag”). If hard to see, have patient pant like a dog (short, rapid breaths) HOWEVER do NOT want tongue protruding from mouth as alters musculature & may effect movement/observations. REPAIRED VS. UNREPAIRED: if not noted earlier, note at this time BIFID UVULA: note if the uvula is bifid or split (May indicate submucous cleft palate BUT occurs fairly commonly in general population THEREFORE MAY or MAY not have significance.) ZONA PELLUCIDA: bluish line down middle of velum. Occurs because velum is thin/sort of transparent due to lack of muscle. May indicate SMCP. DO NOT CONFUSE with a white line down the middle. This is NORMAL. It is the MEDIAN PALATINE RAPHE. Area where levator veli palatini muscle interdigitates at midline (SHOW WITH HANDS).

Functions Assessed: Soft Palate Assess/Observe: degree of movement
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 FUNCTION: Soft Palate DEGREE OF MOVEMENT: note how much the velum moves. Is there a good amount of movement OR is it only fair Or is it only minimal OR is there no movement at all? DIRECTION OF MOVEMENT: along with looking at the symmetry of movement, look to see if the velum moves UPWARD & BACKWARD FLUIDITY OF MOVEMENT: look to see if movement is SMOOTH or JERKY/imprecise (moves back & then comes forward too soon) This may indicate neuromotor dysfunction from a number of causes: dysarthria, apraxia, cerebral palsy, traumatic brain injury etc. PHARYNGEAL MOVEMENT: if possible to see, note if side walls of the pharynx (pharyngeal area) move inward OR note if there is a bulge on the posterior pharyngeal wall (Passavant’s ridge). If this is seen intraorally, it is too low to help in VP closure (as it sometimes does). WITH ALL OF THESE MOVEMENT OBSERVATIONS IT IS VERY IMPORTANT TO REMEMBER THAT VP CLOSURE CANNOT BE EVALUATED INTRAORALLY! IT MUST BE VIEWED FROM ABOVE THE PORT. This is because the INTRAORAL VIEW IS BELOW THE POINT OF VP CLOSURE. AND.. What is seen intraorally may NOT be what is seen from the NASAL side (both structure & function).

Structures Assessed: Other Assess/Observe: tonsils pharynx epiglottis
Assessment-Oral Mechanism/Oral Peripheral Examination cont’d. Procedure Structures Assessed: Other Assess/Observe: tonsils pharynx epiglottis craniofacial/other anomalies (eyes, ears, hands, etc.) Structures: Other There are various other observations that can be made whether within the oral cavity OR with other body features. This WILL NOT be an exhaustive list of them. TONSILS: note if the tonsils are enlarged. Are they visible or not? Do they enter the oral cavity? Are they touching? Is one larger than the other? If so, which one? There is a rating scale for tonsillar size. As a SLP you most likely WON’T rate tonsillar size, but this provides a reference for ratings from physicians. 0=absent tonsils 1=small, fit within confines of faucial pillars (bilateral curtain-like structures in posterior oral cavity, anterior (velum curves down to tongue) & posterior (just behind anterior) 2=tonsils go to edge of pillars 3=tonsils go beyond pillars 4=tonsils are very large, meet at midline, or go past midline

Structures Assessed: Other cont’d.
Assessment-Oral Mechanism/Oral Peripheral Examination cont’d. Procedure Structures Assessed: Other cont’d. CRANIOFACIAL & OTHER ANOMALIES: There are any number of craniofacial anomalies or other anomalies that you may observe. This is NOT an exhaustive list, but they may include: Eyes Ears Hairline Hands Fingers Shape of the Skull Skin You should note/write down ANY unusual observations WHETHER you know if they ARE or ARE NOT SIGNIFICANT. They may help in the overall diagnosis (including syndromes) of the patient.

Additional Assessment/Technique Information:
Assessment-Oral Mechanism/Oral Peripheral Examination cont’d. Procedure Additional Assessment/Technique Information: Compare normal vs. abnormal Judgment improves with experience It takes PRACTICE to do most things in life AND the oral mechanism exam is no exception! First of all, in order to understand/observe ABNORMAL structure you need to understand/observe NORMAL structure. So… you know this means practice on as many people as you can…relatives, your own children, spouses, significant others, friends, students/patients (children) without clefts/craniofacial anomalies. Second of all, your judgments will improve with EXPERIENCE. It’s not easy at first to tell if a palatal vault is too high or narrow, or if tonsils are enlarged etc. Over time, this should become easier as you do more of these exams & as your CONFIDENCE in what you’re seeing increases. “Cut yourself some slack”. You know, Rome wasn’t built in a day. If you have other SLPs (or work with ENTs, plastic surgeons, dentists) available SEEK a second opinion/help. If you work on a team & the opportunity presents itself, LOOK in the mouth at the SAME TIME as the surgeon etc. GAIN THEIR INSIGHT/OBSERVATIONS. ASK for EXPLANATIONS.

Additional Assessment Technique/Information:
Assessment-Oral Mechanism/Oral Peripheral Examination cont’d. Procedure Additional Assessment Technique/Information: Assessing infants & toddlers Your assessment/examination with INFANTS & TODDLER will probably be limited, IF AT ALL! Make what observations you can, but don’t get “hung up” on the NECESSITY to do a COMPLETE exam. Yes, the oral structure exam & it’s results are going to give you some insight as to the patient’s articulation/oral motor/ resonance difficulties etc. BUT A diagnosis can still be made (possibly tentative), progress can still occur in therapy, you will probably gain information from others, & there is still time. I don’t PUSH to accomplish this UNLESS I strongly suspect a structural issue that has YET to be diagnosed. (This is more likely to occur on a stand-alone evaluation than a team evaluation/appointment.) I do have the LUXURY of being on a team where hopefully the surgeon or someone else has at least gotten a cursory look at the structure.

Additional Assessment Technique/Information:
Assessment-Oral Mechanism/Oral Peripheral Examination cont’d. Procedure Additional Assessment Technique/Information: Assessing the less cooperative patient Pretty much what I just said regarding infants/toddlers CAN BE APPLIED to the LESS COOPERATIVE PATIENT . However, you can also use some of these strategies: Make a game of it (let them look in your mouth). Let them have a flashlight/use an animal flashlight. Let them wear gloves (but have them wash their hands after removing them & throw them away. Don’t let them keep. Risk of inhalation) Use fun reinforcers and reinforce for every time that they let you look in their mouth or when they do one of the requested tasks (“try to touch your nose with your tongue”). Slowly introduce the use of the glove. Keep the gloved hand on YOUR side of the table. If this is a therapy patient, only introduce the glove at one session, & try to do more of the exam at a subsequent session. REMEMBER THEIR EXPERIENCE OF PEOPLE LOOKING IN THEIR MOUTHS HAS PROBABLY BEEN NEGATIVE!

Assessment-Order of Rationale
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 This is my personal preference for order of assessment. Rationale: I want to GET THE MOST INFORMATION I CAN TO MAKE THE MOST ACCURATE DIAGNOSIS I CAN TO PROVIDE THE BEST POSSIBLE OUTCOME FOR THE PATIENT!!!!! For those of you who attended my presentation on therapy, this is the area that relates to John Wesley (founder of Methodism, I am a Methodist).

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

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 Possible Issues with Cleft Lip &/or Palate &/or Velopharyngeal Inadequacy: There are many problems that can be associated with CLP/VPI. I will only briefly cover some. FEEDING PROBLEMS: As you can imagine, feeding an infant with an unrepaired cleft (lip or palate) can have it’s challenges. Special bottles may need to be used. The child needs to transition to cup drinking PRIOR to palate repair BECAUSE the sucking motion that occurs with bottle feeding CAN BREAKDOWN the surgical repair. If feeding problems are NOT resolved, there can be issues with poor weight gain/growth. In order to repair the palate, the child needs to have had adequate weight gain. Most feeding problems CAN be resolved with proper techniques. Education of the caregiver is VERY IMPORTANT. A nutritionist/dietician is a very important team member!

Importance of the Team Approach to Treatment
Why team management? Benefit for the patient/family Benefit for the professionals If hearing everything I’ve covered so far hasn’t shown you the NEED FOR A TEAM APPROACH, let me tell you a few more things. BENEFIT OF TEAM CARE FOR PATIENT/FAMILY: Cleft Lip &/or Palate & Craniofacial Anomalies are very complex. Often there are multiple issues. Many areas impact other areas. (surgery impacts speech) Not unusual to need to co-ordinate treatments/procedures. (tubes w/lip repair) Treatment most likely will occur over many years. (usually until adulthood/full growth) One professional CANNOT treat all these areas! It is a big responsibility for families to solely coordinate all the areas involved. To share information from one professional to another. (even with good record keeping) A team Evaluation is more COMPREHENSIVE. Members are usually “experts in their field”, have worked more collaboratively & THEREFORE a better OVERALL PLAN OF care can be developed. Fewer appointments (impacts time/travel/cost). Patients followed by team usually have BETTER FOLLOW-UP & MONITORING. (studies have proven this)

Importance of Team Approach to Treatment cont’d.
The GREATEST IMPORTANCE is that team care helps to provide the BEST OUTCOME for the patient! After all, isn’t that why we do this? At the end of my presentation I will give information on how to contact our teams at Children’s Mercy BUT To find out about other teams please contact: ACPA &/or the Cleft Palate Foundation ALSO…ACPA has standards of care for approval of teams. The standards include: team composition team management & responsibilities patient & family/caregiver communication cultural competence psychological & social services outcomes assessment Standards ALSO INCLUDE how often patient’s should be assessed in various areas.

Guidelines for Referrals for Perceptual &/or FFVN (Instrumental) Evaluations
Perceptual is done before FFVN in order to determine if FFVN is warranted. What I have discussed today has been the PERCEPTUAL evaluation.

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 As indicated previously, PERCEPTUAL is what you hear with your ear. Does NOT involve instrumental or “high tech” assessment. PERFORM W/I 6 MONTHS OF STUDY: This gives us a more current/accurate assessment of skills (resonance, articulation etc.) SCHEDULING PARAMETERS: We are trying more to NOT SCHEDULE THE PERCEPTUAL & FFVN STUDY ON THE SAME DAY. The scheduling variables (behavior, fatigue, time) impact this. It is A LOT for the patient to do in one day. ALSO, we do most of the studies on the SAME DAY as cleft palate clinic. We do realize there are extenuating circumstances (ex. distance traveled) that may make it better for the family to have both procedures scheduled for the same day.

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) Children with normal sound development DO NOT DISTINGUISH the difference between oral & nasal sounds until approximately 2 years of age or older. If we assess a young child (2 or under), is it that they use nasal sounds for oral sounds because of VPI/A OR developmentally do they NOT YET DISCERN the difference? This is not unlike not expecting a 2 year old to correctly produce /r/.

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 Current teams.

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 oral-motor involvement Pre-tonsillectomy &/or adenoidectomy at high risk for VPI/A following surgery Post-tonsillectomy &/or adenoidectomy CLEFT PALATE: Prevalence of resonance disorders that require surgery/prosthesis in individuals with cleft palate is 20-30%. NEUROLOGICAL IMPAIRMENTS: remember the VIN diagram PRE-TONSILLECTOMY &/or ADENOIDECTOMY: pre-T&A WHO ARE at high risk—cleft palate, hypernasal, hyponasal, suspect syndrome either by medical history or looks etc. POST-TONSILLECTOMY &/OR ADENOIDECTOMY: REMEMBER the patient may be using the adenoid pad to aid in VP closure. Tonsils usually do not help closure & as previously indicated, enlarged tonsils may HINDER VP closure.

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 HYPERNASAL VOCAL RESONANCE SPEECH IMPAIRMENT PRE-MAXILLARY ADVANCEMENT: When maxilla is advanced, palate moves forward with it. May create VP gap. May still need to advance, BUT can at least PREDICT if advancement may CAUSE VPI/A or WORSEN any current VPI/A.

Referral Guidelines for FFVN Suspect Nasal Obstruction
Hyponasal or denasal vocal resonance Post-pharyngeal flap surgery Pre-tonsillectomy &/or adenoidectomy Obstructive Sleep Apnea HYPONASAL OR DENASAL VOCAL RESONANCE: look for obstruction or cause of hyponasality POST-PHARYNGEAL FLAP SURGERY: pharyngeal flap may have caused obstruction & affect speech & airway PRE-TONSILLECTOMY &/or ADENOIDECTOMY: look for obstruction in oral cavity by tonsils &/or obstruction in nasal cavity (choanae) by adenoids OBSTRUCTIVE SLEEP APNEA:

Referral Guidelines for FFVN Present with Vocal Disorders
Affecting: Pitch Quality Intensity Allows view of laryngeal region during speech to possibly see what might be negatively impacting these voice parameters/characteristics.

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 POSSIBLE or KNOWN DISORDER OF STRUCTURE &/or FUNCTION OF LARYNX: Vocal cord nodules, polyps, webbing etc. Vocal cord dysfunction Define vocal cord dysfunction: Patient is closing off airway on inspiration. May occur after prolonged or chronic respiratory condition. The closing of the airway has become a habit, though is not intentional. Patient may describe feeling that they “can’t get air in, tightness/pain in vocal cord region” or other symptoms. There isn’t a physiological or medical reason for the dysfunction to continue to occur. Endoscopy can show them visually what the vocal cords are doing. Can be used as part of treatment.

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 We don’t’ need to waste either the patient’s time or our time and evaluation slots by doing unnecessary studies. If we don’t follow our guidelines and have an unsuccessful study with a patient who has a STRONG POTENTIAL for needing a FFVN in the future, we don’t want to “burn bridges” &/or leave a negative impact with either the child &/or the family that may impact our success in the future and ultimately impact child’s potential for normal speech & resonance. We know that “down the road” we will most likely NEED to complete a FFVN study in order to BEST help the patient.

Guidelines for Referral for Perceptual &/or FFVN (Instrumental) Evaluation
If in doubt, give us a call! At ask to speak to Claudia Magers, MS, CCC-SLP (Toll Free: ) At ask to speak to either Sally Helton, MS, CCC-SLP or Sabrina Wallace, MS, CCC-SLP (Toll Free: )

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 (Hearing & Gillham Rd.) Toll Free: We have 3 cleft palate plastic surgeons: Dr. Virender Singhal Dr. Shao Jiang Dr. Alison Kaye We have a main campus clinic(24th & Gillham, Kansas City Missouri). We also have clinics at Children’s Mercy South (near I-435 & Nall, Overland Park Kansas). Currently, the South clinics are held in both the South hospital building AND in a private medical building at College Blvd. & Nall. Hearing & Speech-South is located in this building as is ENT, where we hold some clinics. The contact person is Stephanie Taylor who is the Cleft Palate Coordinator. Phone calls/referrals are made to her & she will determine which team (surgeon) the child will see. Stephanie can be contacted through the Hearing & Speech Department at the main campus. Either through the department’s direct line or by our toll free number.

Final Thoughts Partnership:
-CMHC SLPs are in partnership with you the treating SLP -we all ultimately want the best outcome possible for these children We both have strengths to contribute in helping these children. This is part of our CONNECTIONS. It’s ok if we play “telephone tag” for a while. Let’s both be open to an exchange of information & ideas. CMHC SLPs are here to help you. It seems like we’re back to John Wesley’s statement about doing all the good we can with all the means we can in all the ways we can etc.

Initial contact: by phone Authorization/Releases
Contact Information Sally Helton Hearing & Speech (direct line) Initial contact: by phone Authorization/Releases I am more than happy to discuss diagnostic or therapy techniques individually with you. I prefer that the first contact be by phone as I feel the information can be conveyed better in that manner. Sometimes subsequent contacts can be through .. Without a specific release for a patient, I cannot discuss any information particular to that child. I CAN, however, speak in regard to general diagnostic, therapy terms, principles etc.

“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. This is true whether I’m doing DIAGNOSTICS or THERAPY and, of course, ANY GOOD THERAPY is DIAGNOSTIC in nature. Remember “Pathologist” is in our title—that PERTAINS TO THE DIAGNOSTIC portion of our jobs. This is how we “GET CONNECTED” to these patients/students/children etc.

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

KSHA Conference Presentation 10/01/2010

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KSHA Conference Presentation 10/01/2010

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