DIAGNOSIS, EVALUATION AND THERAPY PLANNING FOR VELOPHARYNGEAL INSUFFICIENCY Virginia Dixon-Wood, MA CCC-SLP University of Florida Craniofacial Center UF Speech and Hearing Clinic

Common Misconceptions Any speech pathologist can treat children with VPI Hypernasality is the major speech problem Speech therapy won’t help until surgery is done VPI is a voice disorder Refer to ENT or neurologist

Insufficiency vs. Incompetency Structurally based -cleft palate, submucous cleft Motor based - stroke, cerebral palsy, low tone, TBI Mix- VCFS (22q-)

PRE-NATAL COUNSELING Cleft lip only Potential for cleft palate based on severity (width) of cleft lip Up to 50% of families now know prenatally In the long run, families do much better

Birth to 6 months Feeding instruction and counseling Speech and Language development Hearing related issues

SPEECH COUNSELING Many children may never need speech therapy Palate closure at 8-12 mo. Six month speech evaluations Parent counseling

6 months- 1 year REEL Scale 2 Receptive-Expressive Emergent Language Scale – Bzoch Birth to 3 years

6 months – 1 year Discuss surgery (9-12 months) Parents expectations Surgery counseling

12 mo. - 2 years Begin phonological inventory range of sounds oral/nasal contrast REEL Scale – refer for EI Parent counseling

Stages of Speech Development Vocalizations - birth Babbling - C+V repetition, 3 mo. Jargon - mixed C+V, 8 mo. First “true word”- 10-12 mo. Two word combinations - 18 mo.

Early Speech Development Cleft m, n g y, h, w Non- cleft m, n d, b, p, g y, w

Speech Characteristics of the Young Child with Possible VPI Delayed expressive language development Very limited phonologic inventory - m,n,h,y and some vowels Use of speech template Consistent nasal substitutions

Early Speech Development Sound differentiation Nasal vs. Oral bye-bye vs. mye mye bye-bye vs. i i bye-bye vs. ? ?

Preschool Can assess palatal function Informally – predominately nasals and vowels vs. combination of nasal and pressure sounds Stimuli – baby, puppy, bye bye Formally – Measures of nasal emission and articulation testing

Speech Characteristics of VPI Glottal compensations Nasal substitutions Inappropriate nasal air emission Weak pressure consonants Hypernasality

Preschool Evaluation of VPI: Sound Production Audible nasal emission Glottal Compensations

Perceptual testing Nasal emission Articulation Resonance Intelligibility

Communicative Disorders Test Kenneth R.Bzoch Designed for specific speech characteristics of cleft palate clients Articulation Resonance Nasal emission Voice - hoarseness, aspirate voice quality

Audible nasal air emission Inappropriate air leakage through the nose during the production of consonants Tested on high pressure sounds - plosives or continuants /p,b,s/

Nasal Air Emission Tests inappropriate nasal air escape during the production of high pressure consonants /p,b/ Use visual or auditory feedback - p-paddle, mirror, listening tube Base 10 index Document change

Resonance Relationship between size of oral and nasal resonating cavities Normal resonance – balanced VPI creates a increased nasal resonating cavity Cold/allergies create a decreased nasal resonating cavity

Resonance Perceived during vowel production Cul-de-sac testing Listener perception

Hypernasality Abnormal amount of nasal resonance Negative impact on listener Perceived during vowel production Tested on vowels with oral consonants beet, bit, bait, bought, boat

Hyponasality Too little nasal resonance Not perceived as negatively by listener Common cold, allergies, sinusitis, enlarged tonsils and adenoids, pharyngeal flap Cul-de-sac testing Nasometry

Hypernasality Vowels with /b/ If resonance is normal (oral)- there should be no difference between the 2 productions Base 10 index Document change

Hyponasality Vowels with /m/ If normal resonance, there should be a difference (shift) between words Base 10 Document change

Significance Indexes of 3/10 or greater Do indexes match what you are hearing in conversational speech? Impact on the child and/or family?

Voice Vowel prolongation- timed Aspirate -may be compensation to conceal hypernasality Hoarseness - may be caused by glottal compensations

Error Pattern Diagnostic Articulation Test Developed for patients with cleft lip/palate Based on manner of production Classifies many different errors - correct, NE, distortion, simple/glottal substitution, omission Error and articulation scores Documents change

Speech Sample Spontaneous single words Conversation Estimate a % Does it validate your other test results?

Palatal Fistulae Opening along the suture line Assess size (mm) Document location Can be responsible for abnormal articulation patterns Nasal emission

Fistula Important part of oral exam Anterior fistulae - impact on articulation Nasal emission - may be inconsistent or phoneme specific Resonance - may be normal

Fistula Recommendations based on speech results: surgical closure obturate do nothing

NOW WHAT ?

Creating the Treatment Plan Age Articulation vs. resonance Severity of articulation disorder What is interfering the most with intelligibility Child and family reaction What can you treat?

SPEECH THERAPY WHAT? WHY? WHEN? HOW?

Treatment Plan You have to understand the problem before you can create a treatment plan Not understanding the problem can create additional articulatory compensations Can waste valuable time and money

Treatment Plan Nasalized – diagnostic therapy to see if child can impound oral pressure (short term) Glottal compensations – help the child learn to create oral breath pressure

What NOT to do Muscle Training: (Cole, 1979) Indirect Semidirect

What NOT to do Yules, 1968 Subjects were able to reduce nasal emission on short tests but that establishment of performance in automatic speech remained to be demonstrated

What NOT to do McWilliams-no evidence that muscle training had any impact on improving speech or reducing nasal emission

Misarticulations Judy Trost-Cardamone, 1997 Obligatory errors - physical management hypernasality, nasal emission, weak pressure consonants Passive/Learned Errors - compensatory errors, phoneme specific

Treatment Planning Child 1 Increase movement of articulators Vowels Increase intelligibility /m,n,y,h,w,l/ Frication Pressure sounds

Treatment Planning Child 2 Develop oral air flow Vowels Increase intelligibility /m,n,y,h,w,l/ Frication Pressure phonemes

Speech Therapy Delayed speech development in young children but without glottal compensations Nasal emission distortion/unintelligible speech Poor articulatory movement

Speech Therapy Goal: Improve articulation/intelligibility Hypernasality and nasal emission are not priorities Improve movement of articulators Accurate vowel production Low pressure consonants

Speech Therapy Delayed speech development with glottal compensation Improve intelligibility Establish oral airflow - this is imperative Can create “popping” or “clicking” for pressure sounds

Speech Therapy Child with glottal compensations: Improve articulatory movements Accurate vowels Low pressure consonants - oral airflow Frication Plosives

Speech Therapy Glottal compensations Sonorants Unvoiced Final position

Speech Therapy Glottal compensations- Begin with ANTERIOR sounds

Speech Therapy Multisensory Not successful at duplicating what they have heard Visual Tactile Kinesthetic

Speech Therapy Glottal Articulation TEACHING PLACEMENT IS NOT ENOUGH CAN CREATE CO-ARTICULATIONS

Palatal Fistula vs. VPI Obturate fistula Speech therapy - 3-6 months Objective testing

VIDEOFLUOROSCOPY Poor candidates: compensatory articulation poor articulation skills significant palatal fistula very young or uncooperative child

Impact of Articulation on Velar Function Glottal articulation can “shut down” palatal movement Often there is little movement of the articulators as well Palatal fistulae can also impact velar function