Assessing Resonance

comprehensive assessment of clefts

• detailed case history

• hearing screening

• oral mechanism exam

• resonance-hypo/hypernasality, cul-de-sac, or mixed

• articulation- usually related to VPD (compensatory articulation)

• Feeding/swallowing- usually related to VPD (nasal regurgitation)

• Language- may be related to syndrome

Diagnostic Interview

Caregiver or patient fills out

questionnaire

• Form needs to include questions

about

• Resonance

• Phonation

• Articulation

• Feeding/swallowing

• Language

• Clinician asks probing questions to fill

in gaps from the questionnaire

feeding/swallowing screening

• Many patients with

  resonance issues related to

  VPD also report issues with

  swallowing

• Nasal regurgitation is

  commonly reported by

  patients

• Gagging or globus (feeling

  of food stuck in the

  pharynx) is sometimes

  reported

• n adults with degenerative

  disorders, VP function and

  swallow function may be

  first signs of the disorder

  •SLP may be first professional to

  identify the neurodegenerative

  disease and will need to make

  further referrals to the

  neurologist and other

  professionals

Language Screening

Children with cleft lip/palate are at increased risk for language delay

• Best practice is to conduct a language screening annually

• Formal language screener or language sampling procedures

• Comprehensive language evaluation should be done for children with

• Syndromes

• Hearing loss

• Neurological issues

• Other risk factors

• Adults with degenerative diseases often have language and cognitive

deficits as well, so it’s always good to screen for these areas

Articulation, Phonation, and resonance Diagnosis

• Begins with a perceptual assessment

• Perceptual assessment is far more important than

• instrumental

• This will determine if instrumental assessments need to

• be performed - can save time and money

• Survey of 126 SLPs found 99.2% of SLPs on cleft teams

• use perceptual assessment of VPI (Kummer, 2012)

• Listen for articulation of speech sounds, phonation, and resonance

Perceptual assessment:

SLP uses

clinical judgment to determine if

hypernasality or NAE is present, and

makes inferences about VP function

If the perceptual assessment shows no speech abnormality, then it does not matter what the instrumental assessments show… why?

no treatment is warrented

If there is a speech abnormality

perceptual

assessment should determine if it is structural

or functional

Judgment of phonation

determine if full voice evaluation is needed

perceptual assessment

• Perceptual assessment is sufficient to diagnose type of resonance disorder

(hypernasality, hyponasality, etc.)

• Strategically using different speech samples, such as comparing an all oral passage vs a nasal-loaded passage, can facilitate differential diagnosis for type of nasality

formal articulation tests for cleft patients

• Typically only assess word level, some have

sentences also

• Usually neglect other levels of the

articulation hierarchy, but SLP can probe

• Does not take into account co-articulatory

or context effects

• Often too time-consuming in a medical

setting

• GFTA-3

• Arizona-4

• Iowa Pressure Articulation Test

• Templin-Darley Tests of Articulation

• Bzoch Error Pattern Diagnostic Articulation

Test

counseling

• document phonetic inventory

• note phonological development errors

• rate overall intelligibility

  • parent rating scale such as (ICS)

use of speech samples

Use of speech

samples is highly

recommended in this

population (adults

and children)

what do we assess in speech samples for patients with cleft palatte?

Assess speech

production,

resonance, and

phonation

simultaneously

what do we not focus on in a speech sample for a child with cleft palatte?

Do not focus just on word level, but includes isolation, syllables, sentences, and connected speech

things to consider in speech samples

Consider

developmental

guidelines for speech

sound production

and syntax in children

• Must determine if it is a

developmental error,

obligatory error, or a

compensatory error

caused by the

structural/functional

deficit

follow up

• referral to radiology, ent, neurology, sleep study, etc

• recommendations: st??? frequency

• counseling: family counseling, genetic counseling

• evaluation report: no standardized method, should contain all components of all typical evaluation (like the ones in our clinic)

nasometry

Assesses hyper/hyponasality, NAE, and VP function

Survey of 126 SLPs found 28.9% use nasometry (Kummer,

2012)

Only 19% of SLPs who work on cranio teams use

nasometry

Far fewer SLPs who work in other settings use nasometry

Almost no SLPs in public schools or private clinics use

nasometry

Some universities use it, but usually only if needed for

research

nasometry

• Separator Plate divides nasal airflow from oral

airflow

• Standardized passages are repeated or read

aloud

• Measures nasal airflow (N) and oral airflow (O)

• Calculate nasalance score by dividing

N/(N+O) and convert to a percentage

• Nasalance = % of nasality in speech

• Nasalance distance: range between

maximum and minimum nasalance

• Nasalance ratio: minimum nasalance

divided by maximum nasalance

nasomtery in treatment

Provides real-time visual

feedback about nasality

Treatment is only useful if

the patient is anatomically

and physiologically capable

of closing VP mechanism

during connected speech

Indicated for phoneme-

specific learned

hypernasality

Helpful for post-surgical

treatment when patient is

learning to use newly

corrected anatomySLP sets goal by creating a

reference line, and patient

works to keep their

nasalance line below

reference line

As patient makes progress,

reference line can be moved

little by little until the

patient matches normative

score

speech aerodynamics

• Measures the airflow and air pressure

in the oral and nasal cavity during

speech to:

• Estimate airway obstruction by

measuring nasal airway resistance

• Calculate the size of the VP

opening

• Survey of 126 SLPs found 4.3% use

aerodynamics (Kummer, 2012).

• Used more in research than actual

clinical practice

“Orifice

Equation”

• Cross-sectional area across the

opening of any orifice (including the

VP port) can be calculated if you

know:

• Air pressure before the orifice

(Point A)

• Air pressure after the orifice

(Point B)

• Air flow through the orifice

Pressure-Flow Technique

• Insert one pressure transducer into oral cavity (Point A)

• Insert second pressure transducer into nasal cavity (Point B)

• Insert flowmeter into other nostril to measure air flow through VP port

placement of oral transducer must be behind place of artic

• If there is a moving airstream, the open end of the catheter must be perpendicular to flow

• Bilabial stops are usually the easiest placement for the transducer

reported measures can be compared to norms

• Air pressures will be reported as cm H2O

• Air flow will be reported as mL/sec

• VP area will be reported as mm2

“Orifice Equation” Applied to the Nasal Cavity

Anterior

Rhinomanometry: nasal

resistance and nasal area

are measured for both

nostrils during quiet

breathing

• Uses tubing placed in each

nostril one at a time

Posterior

Rhinomanometry:

nasal resistance

and nasal area are

measured for each

nostril during quiet

breathing

• Uses a mask placed

over the whole nose

Patient scores must

be compared to

aged norms, as the

face grows

dramatically

throughout

childhood changing

the average cross-

sectional area of

the nasal cavity

direc

• Videofluoroscopic Speech Study (VFSS)

• Video Nasendoscopy Evaluation of Speech (VNES)

• Allow direct visualization of anatomy and physiology during

speech and swallowing, but actual assessment is subjective

• See cause of VPD

• Determine location of VP gap

• Determine pattern of VP closure

• Assess placement of prosthetic

• Pre- and post-operative assessments

• VFSS was gold standard until 1980s

• 59.3% of SLPs use VNES and 19.2% use VFSS (Kummer, 2012)

direct instrumental procedures

MRI can also be

used

Disadvantages =

too loud for some

children,

claustrophobic, too

expensive

MRI may eventually

replace

videofluoroscopy

as technology

becomes cheaper

For now, MRI is

mostly used in

research

applications

because the clarity

of the images is

very good

VFSS and VNES Speech Sample

Must tax the

velopharyngeal

mechanism to induce

VPD in mild cases

Repetition of sounds,

syllables, words, and

sentences

Use high-pressure

phonemes with high vs

low vowels

•/pa/ /pa/ /pa/ vs /pi/ /pi/

/pi/

Use front and back

consonants

•/pa/ /pa/ /pa/ vs /ka/ /ka/

/ka/

Prolong /s/ sound Reading of passages,

age permitting Counting 60-70

videofluroscopy

• With patient supine, use a syringe to inject barium into both nostrils

and instruct patient to “sniff it up”

• Rotate head to evenly distribute

• Will coat nasal cavity, nasopharynx, and oropharynx

• Use multiple positions while patient repeats the speech samples

(VFSS is 2-D, so multiple views needed to reconstruct 3-D port)

• Lateral (sagittal) view: visualize velar lift, adenoids, posterior

pharyngeal wall, lingual movement

• Frontal (a-p) view: visualize lateral pharyngeal wall

movement and septum

• Base (bottom-up) view: visualize the circular port from

below

• Towne’s (top-down) view: visualize the circular port from

above

• Oblique view: visualize the port at a 45 angle on the right

and the left = used with large adenoids or patients with

asymmetrical lateral pharyngeal wall movement

video nasoendoscopy

• Minimally invasive direct visualization of

nasal, pharyngeal, and laryngeal cavities by

inserting a flexible camera scope thru nose

• Used during speech sound production or

swallowing to observe function

• Full color, high resolution cameras provide

maximum visibility

• No barium or radiation required

• Can be performed by an SLP independently

• Much more cost effective that fluoroscopy

• Patient completes speech sample