PMI Exam 2

What kind of assessments do the SLPs do?

functional assessments

How do you test for HYPERnasality? (single sounds)

have the child prolong different vowels /i/ /a/ /u/

How do we test for nasal emission? (single sounds)

have the child prolong /s/ or any other HIGH FRICATIVE sounds

How do we test for HYPOnasality, cul-de-sac, or airway obstruction? (single sounds)

have the child prolong /m/

does it sound like they have a constant cold?

How do you test for HYPERnasality? (syllables)

repeat syllables of voiced consonants

ba ba ba ba

How do you test for nasal emission? (syllables)

repeat syllables of voiceless consonants

pa pa pa pa

How to test for HYPOnasality, cul-de-sac, or airway obstruction? (syllables)

repeat syllables of nasal sounds

na na na na

What is the point of assess speech sound production?

helps you assess and identify obligatory vs. compensatory errors

How to test for HYPERnasality and nasal emission? (counting)

have the child count from 60-69

This taxes the VP port and movement (assess function)

How to test for HYPOnasality? (counting)

have the child count from 90-99

asses /n/ in connected speech

How to test for speech sound production and resonance, as well as screen for language?

load each sentence with phonemes that are produced with the same placement

take the teddy to town

do it for daddy

i see the sun in the sky

How to elicit spontaneous conversational speech?

verbal sequencing

tell me how to make a peanut butter + jelly sandwich

What structure abnormalities of VPI & cleft palate are seen with OBLIGATORY distortions?

• nasalization of oral phonemes

  • m/b

  • n/d

  • eng/g

• nasal emission

What structure abnormalities of VPI & cleft palate are seen with COMPENSATORY distortions?

• glottal stops

• pharyngeal fricatives

• pharyngeal plosives

What sound should be used in the examination of the oral cavity and why?

/æ/ as in hat

the tonsils will move laterally allowing us to see more

What structures should you be able to see in the oral cavity examination?

tonsils

whole palate

uvula

velum

Why should we palpate the oral cavity?

to find submucous clefts

notch will only be felt if the submucous cleft extends all the way to the bone of the hard palate

What is the function of a dental mirror in the examination of the oral cavity?

use to examine the hard palate and see a fistula

What are characteristics of oral-motor dysfunction?

drooling, open-mouth posture/dropped jaw, anterior tongue position, history of feeding problems

ask parents about these characteristics

Types of Indirect instrumental procedures

• does not visualize the VP structures

  • Nasometry

  • Aerodynamics

What kind of information does Indirect procedures give us?

gives us objective information regarding physical correlates (acoustics, airflow, air pressure)

allows for comparison of pre vs. post treatment results in order to determine outcomes

Types of Direct instrumental procedures

• visualizes the VP structures

  • Videofluoroscopy

  • Nasopharyngoscopy

What kind of information does Direct procedures give us?

direct visualization of the structure and function of VP valve furing speech

important for determining the location and probable cause of the opening or obstruction

What is nasometry?

a method of measuring the acoustic correlates of resonance and VP function through a computer program

What information can we gather from Nasometry?

it gives us a nasalance score

it helps evaluate VP function and resonance more objectively

Standardized test

What are the clinical indication of Nasometry?

historically used with people who have cleft palates

• beneficial for kids

• nice biofeedback DURING therapy

• can see before and after’s

Standardized Passages in English

Kids: SNAP-R

Adults: Zoo passage, Rainbow passage, Nasal passage

• nasalance score is compared to normative data for that passage

Nasogram

a contour display of individual data points in sequence as they are collected in real-time during production of a passage

can be changed from a run chart to a bar graph

What does HYPERnasality look like on a nasogram?

a super high placed dot

What does HYPOnasality look like on a nasogram?

a super low dot

What does a high nasalance score indicate?

the higher the score, the more HYPERnasality or audible nasal emission

What are the expected results for nasalance?

Normal: < 20%

Mild HYPERnasality or nasal emission: 30-40%

Clear HYPERnasality: > 40%

What type of imaging is a Videofluoroscopy?

live x-ray imaging

What are the uses of videofluoroscopy?

• confirm the presence of a VP opening and estimate the size

• differentiate the cause of VP

• show the vertical movement of the velum during speech

• provide a view of the entire length of PPW

• evaluate the effects of surgical procedures

Lateral View of Videofluoroscopy Basics

• patient sits upright or lays on their side

• beam enters side of the head

• shows the velum and PPW in a midsagital plane

Give a small amount of Barium so it coats certain structures so that they light up on the x-ray and make them easier to see

What can we see from a lateral view Videofluoroscopy?

• effective length and height of the velum during speech

• velar movement

• PPW

• tongue movement

• patency of fistula when barium is in the nasal cavity

Frontal (AP) Videofluoroscopy Basics

• patients sits upright or lays on their back

• beam enters through the front of the nose

• shows the LLW at rest and during speech

Base (En Face) Videofluoroscopy Basics

• patient lays on their stomach with their head up

• beam enters through the base of the chin then up through the VP port

• shows the perimeter of the VP port

Contrast Material (AP and Base) Videofluoroscopy Basics

• patient lays on their back

• barium is instilled into the nasopharynx through: catheter, dropper, pipette

• head is rotated to coat pharynx

What are the speech sample parameters for Videofluoroscopy?

• patient is asked to repeat a combination of sentences that are loaded with pressure sensitive phonemes

• produce a repetition of pressure sensitive syllables

• count from 60-70 and repeat “sixty” many times

Advantages of Videofluoroscopy

provides a view of the entire length of the PPW

shows the point at which the velum contracts the PPW during speech

can identify a short velum versus poor velar movement

Limitations of Videofluoroscopy

radiation exposure - minimal

requires multiple views

relatively poor resolution compared to nasopharyngoscopy

not possible to see small or unilateral gaps

requires barium to be instilled through the nose - uncomfortable

Nasopharyngoscopy basics

minimall invasive

allows for visual observation and analysis of the VP mechanism during speech

widely used for evaluation of VP function

can see EXACTLY what is going on

higher picture resolution

Clinical uses for Nasopharyngoscopy

• can show the size, location, and probable cause of VPI

• also used for evaluation of enlarged adenoids

• nasal surface of velum may reveal evidence of submucous cleft

• absent or dysplastic musculus uvulae

• VP gap in midline corresponding to defect in velum

• nasal surface of the hard palate may show actual suze and extent of an oronasal fistual

Where do you insert the Nasopharyngoscopy scope?

into the middle meatus

• it is the biggest and it doesn’t touch the velum

Speech samples to use for Nasopharyngoscopy

• repetition of syllables with pressure sensitive phonemes

• repetition of sentences loaded with pressure sensitive phonemes

• counting from 60-70 or repeat 60 quickly

• repetition of nasal syllables and sentences and prolonged /m/ to evaluate nasal obstruction

Advantages of Nasopharyngoscopy

• provides excellent resolution and visualization of the structures

• shows the location, size, and shape of opening

• can see very small openings

• can view the result of surgeries for VPI

• Can be done without radiation

• is very well tolerated, even by young patients

• can provide biofeedback

Limitations of Nasopharyngoscopy

• requires a degree of cooperation

• causes (initial) slight discomfort and can be scary for kids

• expensive tool and need further training outside of graduate school

What is the main reason for Cleft Lip surgery?

it is mainly done for aesthetics

What is the main reason for Cleft Palate surgery?

it is mainly done for function

• speech, feeding, middle ear function

Cleft Lip Repair - Cheilorraphy

around 10 weeks of age (between 10-12 weeks)

presurgical management (taping) can be done around 6-8 weeks

• aligning the structures

• achieving symmetry

• achieving a white roll

• minimizing the appearance of scars

Unilateral Cleft Lip Repair Techniques

Millard

Tennison-Randall

Millard Surgical Technique

most common (80% of surgies)

lip is repaired in three layers from inside out

• mucosa (gums)

• muscle (orbiuclairs oris)

• skin

Tennison-Randall Surgical Technique

least common (20% of surgies)

lip is repaired in three layers from inside out

• mucosa (gums)

• muscle (orbiuclairs oris)

• skin

Cleft Palate Repaire (Palatoplasty)

9-12 months, but might be delayed due to intensity of surgery

• separating oral and nasal cavities

• normal VP mechanism

• minimzing the occurance of fistulas

• optimizing facial growth —> repairing bone

The palate is closed in three layers (nasal mucosa, muscle, oral mucosa)

Why is palate surgery more difficult than lip surgery?

• technically more demanding

• dehiscence (partial or total separation of previous approximated wound edges)

• greater risk of fistula formation

Surgery for VPI - Pharyngoplasty

usually after 3 years of age (not speaking in connected speech before then)

• “normalizing” VP closure for speech

• avoiding airway compromise

Alveolar Bone Grafting

not usually closed with lip or palate repair —> wait for growth and permanent teeth

around 6-11 years old

• to provide bony support for permanent lateral incisors and canines

• to improve dental arch

Maxillary Advancement: Orthognathic Surgery

can address malocclusion that often occurs due to clefts and micrognathia

around 14-16 in girls, 16-18 in boys

• to bring the maxilla into proper alignment with the mandible

• improves aesthetics and obligatory speech distortions

Surgical timelines

Lip adhesion: newborn (optional) —> simonart’s band

Lip repair: 3 months

Palate repair: 10 months

VPI: 3-5 years

Bone graft: 6-7 years

Fistula repair: as needed, usually with bone grafts

Lip and nose revision: as needed when school aged

Orthognathic: as needed

Dental Appliances

Fixed Bridge: replaces dental segments

Dentures: replace all teeth in the arch

Overlay dentures: fit over exisiting teeth and provide more vertical dimension

dental implants: implants that are drilled into the bone to help with the retention of a prosthesis

Feeding Obturators —> prosthetic

device that covers or fills a hole/opening (can be for feeding or speech)

• improving compression of the nipple

• reduce nasal regurgitation of liquids

Palatal Obturator

covers an open cleft or large fistula

Palatal Lift

used for treating VP incompetence (only)

helps hold the velum in place against the PPW for speech

Speech Bulb Obturator

used for treating VP insuffiency

replaces the velum

Focus of Intervention: Infants & Toddlers

• feeding

• counseling family on speech/language stimulation

• language therapy

Focus of Intervention: Preschool children

• initial speech/resonance evaluation

• VPI surgery

• speech therapy

more in depth

Focus of Intervention: School-age children

• articulation therapy (if errors are not obligatory)

Focus of Intervention: Adolescents and Adults

• evaluation after maxillary advancement

• VPI surgery

• speech therapy

What is the purpose of speech therapy?

to correct compensatory errors after a correction of a structure

When should speech therapy be done?

ideally, after surgical intervention for VPI

What is the goal for speech therapy before VPI surgery?

to limit nasal emissions

• a lot of tactics should be done at home

Why are listening tubes used in speech therapy?

to provide enhanced auditory feedback

Oral & Nasal Listener (ONL)

allows the SLP (or parent) and child to hear the amplified sound

gives feedback regarding oral airflow and oral speech sound production

• a dual stethoscope

General Principles of Speech Therapy

• start with sounds that are easiest and most stimulable

• start with sounds that will have the biggest impact on intelligibility

• start with anterior sounds, which are most visible

• start with continuant sounds before movement sounds

What is sensory awareness in speech therapy?

making the child aware of wrong sound vs. the target sound

give as many clues as possible using:

• Visual awareness: watch it

• Tactile awareness: feel it

• Auditory awareness: hear it

Therapy for Glottal Stops

contrast the wrong sound with the target sound

• hear the difference

  • start with the /p/ in isolation

  • then produce /p/ and the vowel preceded by an /h/

  • whisper a /b/ and the vowel preceded by an /h/

Therapy for Pharyngeal Plosives (abnormal k/g)

start with an /eng/ placement

• have the child achieve the position then drop the tongue repeatedly to get the up and down movement

• then add a vowel

  • have the child take a breath, place the tongue for /eng/ and drop the tongue for the vowel while pinching the nose

Therapy for Phoneme-Specific Nasal Emission (PSNE)

due to use of either pharyngeal or posterior nasal fricative

• have the child produce a loud /t/ and note the anterior flow

• have the child produce the /t/ with teeth closed

• have the child prolong the production until it becomes /tssss/

• have the child begin without the /t/

Therapy for a Lateral Lisp

occurs when the tongue touches the teeth, alveolar ridge or palate, causing lateral emission of the air stream

occur mainly on sibilants, but can occur on /t/ if there is a delay in lingual release

• put a straw in front of the teeth and then to the sides during the production of /s/

• if normal, air will be heard through the straw in front of the central incisors

• if lateral, air will be heard through the straw and at the side of the dental arch

  • use the same techniques for PSNE

  • use straw for biofeedback of anterior airflow

Therapy for /ɚ/

show the child how the shape of the tongue forms a “boat”

show where the back of the tongue touches the gums behind or just under the upper molars

• stimulate the back of the tongue on each side, and then the upper gum ridge behind the molars

tell the child to “back up the boat”

can also bring the lips back in a smile if necessary

Therapy for /r/

start with /ɚ/ and show the forward movement of the tongue with your hand

tell the child to push the “boat” off the dock

• tell the child to put his hands on his face and go from /ɚ/ to /r/ without moving his face or lips

Therapy for /ŋ/ or /l/ or nasalized vowels

co-articulate a yawn with the /l/ to get the back of the tongue down and the velum up

for biofeedback, have the child use a tube or straw or feel the sides of their nose for any vibration

Who are the core members of a Cleft-Palate Team?

• plastic surgeon

• SLP

• Orthodontist

• At least one other specialist (dietician)

Who are the core members of a Craniofacial Team?

• Craniofacial surgeon

• Orthodontist

• Mental health professional

• SLP