PMI Exam 2 Concepts

Speech/Resonance Assessment, Instrumental Procedures, Surgical Management in Cleft Lip/Palate, Speech Therapy

What does assessment look like for birth to 3, 3-4, annually, and after puberty to 18?

Birth to 3: SLP, Craniofacial team

3-4: More involved SLP assessment

Annually: depends on severity

After puberty to 18: every 2 years be assessed

Why shouldn’t we wait too long to evaluate and treat VPI?

• lots of brain development at 3-4

• critical time for learning

  • less mislearnings

What is the order of a speech/resonance assessment?

1) Diagnostic interview

2) Perceptual assessment goals

3) Instrumental assessment

What are language screenings used for?

• identify risk of language delay

• formal vs informal screening

Perceptual assessment order:

• single sounds

• syllables

• counting

• sentence

• conversational speech

Why is single word perceptual assessment not advised?

Coarticulation is used more

Perceptual assessment: single sounds

How to test for: hypernasality, nasal emission, hyponasality/cul-de-sac resonance?

hypernasality: child prolongs a vowel

nasal emission: child prolongs /s/

hyponasality/cul-de-sac resonance: child prolongs /m/

Perceptual assessment: syllables

How to test for: hypernasality, nasal emission, hyponasality/cul-de-sac resonance, speech sound production?

hypernasality: repeat syllables of voiced consonants - ba

nasal emission: repeat syllables of voiceless consonants - pa, sa

hyponasality/cul-de-sac resonance: repeat syllables with nasal sounds - na, ma

speech sound production: helps assess obligatory vs compensatory error

Perceptual assessment: counting

How to test for: hypernasality and nasal emission, hyponasality?

hypernasality/nasal emission: count 60-69 - taxes VP port

hyponasality: count 90-99 - /n/ in connected speech

What should your tests/passages include to assess nasality?

Each sentence should have phonemes with the same placement

How do you elicit spontaneous conversational speech in perceptual assessment?

Verbal sequencing

What do you do if the client is shy during the conversation part of the perceptual assessment?

Use parent/sibling

What should be evaluated for speech sound production, nasal emission, resonance, and phonation?

Speech sound production: artic

Nasal Emission

Resonance: hypo vs hyper

Phonation: voicing, volume

When evaluating speech production, what errors could be present?

Placement, phonological, developmental

With structural anomalies, determine the presence of obligatory distortions and compensatory errors?

Obligatory: VPI, cleft palate

Compensatory: glottal stop, pharyngeal fricative

When assessing nasal emission, what should be learned?

Type

• Inaudible: large gap

• Audible: medium gap

• Nasal rustle: small gap

Weak/omitted consonants

Short utterance length: 60-70 in 1 breath

Nasal grimace

How to determine differential diagnosis of nasal rustle?

Abnormal structure vs abnormal function

• structure: small VP gap

• function: posterior nasal fricative

What is the most important to determine in resonance evaluations?

Type of resonance or severity

What are the rating scales for resonance?

• 7 point scale

• 6 point scale: normal, mild, mild-mod, mod, mod-severe, severe

• 4 point scale: normal, mild, moderate, severe

• 2 point scale: normal, abnormal

Why are resonance rating scales unreliable?

Everyone hears things differently; rating severity DOES NOT matter

What are supplemental evaluation procedures for visual detection?

• dental mirror: not reliable; if fogs up then some nasal emission

• air paddle: if paper flutters then nasal emission; only works well with a lot of nasal emission

• see-scape: if ball moves then nasal emission, can see feedback

What are supplemental evaluation procedures for tactile detection?

Feeling sides of nose (need lots of nasal emission to feel)

What are supplemental evaluation procedures for auditory detection?

• cul-de-sac test (hold sides of nose shut) - tests hypernasality

• stephoscope

• straw

• listening tube

What recommendations should be given for VPI and VP mislearning after assessment?

VPI+resonance disorders

• surgery/prosthesis

• speech therapy (as needed) after correction for compensatory productions

VP mislearning

• speech therapy

What are the best supplemental evaluation procedures?

straw or tubes

SLPs diagnoses the ___ and ___ of speech/resonance disorder?

type and cause

What should always be done as part of a speech or resonance eval?

Examination of oral cavity (oral mech exam)

What does a examination of the oral cavity evaluate and not evaluate?

Evaluate

• oral structures, oral function

• view well below area of closure

Not Evaluate

• VP structure, VP function

What tools are used for an intraoral exam?

• gloves

• flashlight

• dental mirror

• tongue blades

• sanitizing wipes

• hand sanitizer

How should one position a patient for an oral exam?

• get the right position

• for toddlers/infants:

  • place in parent’s lap facing parent

  • have child lay back so head is over parents knees

  • sit across from parent

  • close child’s nose if necessary

How does crying help during an oral exam?

Can see inside mouth

What does our oral motor assessment consist of?

• Patient says /ae/

• Sticks out their tongue and try touching chin with tongue during phonation

• Use palatal palpation 

• Use dental mirror/blade to see in mouth and all the parts of mouth

What are signs of oral-motor dysfunction?

• drooling

• open-mouth posture/dropped jaw

• anterior tongue position

• history of feeding problems

• difficulty executing oral-motor movements

Why should we palpate the palate?

• To find submucous cleft

  • Only felt if cleft extends all the way to the bone of the hard palate

Speech therapy should began after ____ ______ are resolved?

structural abnormalities

What are the types of instrumental measures?

Indirect (does not visualize VP structures)

• nasometry

• aerodynamics

Direct (visualizes VP structures)

• videofluoroscopy

• nasopharyngoscopy

What does nasometry provide?

• Evaluation of resonance and VP function

• Provides biofeedback during treatment

• Hand-held separator

• Shows scores on nasogram

What equipment is involved in nasometry?

Nasal microphone, oral microphone, nasometer interface box, computer

What is the difference between the old and new version of the equipment in nasometry?

Old: headset

New: hand-held separator

What standardized passages are used for nasometry in adults?

Zoo, Rainbow, Nasal

What standardized passages are used for nasometry in kids?

MacKay-Kummer Simplified Nasometric Assessment Procedures revised (SNAP-R)

What score is compared to normative data for the passage?

nasalance

What is the display of speech signals created from nasometry?

nasogram; data points of what child said

What does high vs low scores mean in nasalance?

• High means -> hypernasal/audible nasal emission

• Low means -> hyponasal

What are the expected results of nasalance?

Normal: less than 20%

Mild Hypernasal/nasal emission: 30-40%

Clear hypernasality: greater than 40%

Is this nasogram normal, nasal emission, or hypernasality?

normal

Is this nasogram normal, nasal emission, or hypernasality?

hypernasality

What does hypernasal speech look like on a nasogram?

High solid and dotted lines

What does hyponasal speech look like on a nasogram?

Low solid and dotted lines

What does videofluoroscopy (VSS) show?

• Confirm presence of VP opening and size

• Differentiate cause of VP dysfunction

• Shows view of entire PPW

What are the most common views of VSS?

lateral, frontal/anterior-posterior (AP), base

What does a lateral view of videofluoroscopy show?

Lay down on side/sit up; shows velum and PPW in left/right plane

What does a frontal (AP) view of videofluoroscopy show?

Lay down flat/sit up; shows LPW at rest and during speech

What does a base view of videofluoroscopy show?

Lay in sphinx position; shows perimeter of VP port

Is this image a lateral, frontal (AP), or base view?

Base view

Who interprets videofluoroscopy?

Radiologist and SLP

How do videofluoroscopy and nasopharyngoscopy differ?

• Videofluoroscopy: uses barium and radiation so used less often, shows entire view of PPW including velum contracts the PPW during speech

• Nasopharyngoscopy: camera down throat, great view of all structures, no radiation, very expensive and requires cooperation

What can be seen in nasopharyngoscopy?

• Can see the size, location, probable cause of VPI

  • VP gap in midline = defect in velum

  • Nasal surface of velum can show submucous cleft

  • Nasal surface of hard palate can show size + extent of oronasal fistula

What equipment does nasopharyngoscopy use?

• Flexible fiberoptic endoscope. Size of scope ranges from 2.2 mm to almost 5 mm in diameter

• Eyepiece with a lever for moving the tip of the scope

• Specially designed camera that attaches to the eye piece

• External microphone

How is the scope passed during nasopharyngoscopy?

• inserted through largest nostril

• scope guided up and over inferior turbinate through middle meatus (biggest)

• once scope in nasopharynx, turn down with lever so that it is perpendicular to the opening

  • can be rotated slightly from one side to the other to see both sides of port

What malformations can be interpreted from nasopharyngoscopy?

• submucous cleft

• oronasal fistula

• irregular adenoids

• tonsillar hypertrophy

• lateral gaps due to bow tie closure

• narrow coronal gap

• large gap

• large VP opening with a Passavant’s ridge

• vocal nodules

What is the timeline of when each surgical procedure occurs?

• Cleft palate repairs: 9-12 months (10 months)

• Cleft lip repairs: 10-12 weeks (3 months)

• VPI surgery: 3-5 years, aren’t speaking much before then

• Alveolar grafts: age 6-11

• Oronasal fistula: as needed when school age, age 6-7

• Orthognathic surgery: 14-16 GIRLS, 16-18 BOYS

What are the types of dental appliance prosthetics?

Fixed bridge, dentures, overlay dentures, dental implants

What are the types of Obturators and what are they used for?

• Palatal, Palatal lift, Speech bulb obturator

• For feeding + speech

What does not work for speech therapy?

Oral-motor exercises

What is the goal of speech therapy?

Normal speech and resonance

What members of the medical team make up the cleft palate team?

• Plastic surgeon

• SLP

• Orthodontist

• At least one other specialist

What members of the medical team make up the Craniofacial Team?

• Craniofacial surgeon

• Orthodontist

• Mental health professional

• SLP

What does each cleft palate team require?

Team Coordinator

What are the types of teams?

• Multidisciplinary

• Interdisciplinary

• Transdisciplinary

What is type of team has members care for patients independently with limited communication?

Multidisciplinary

What type of team has members work together to coordinate plan of care for the patient?

Interdisciplinary

What type of team has members work cooperatively and truly understand each other’s disciplines?

Transdisciplinary

When is speech therapy appropriate?

• Ideally after VPI surgery

• Before if goal is to limit nasal emission

• Compensatory errors

• Placement errors that are mislearned

• Biofeedback

When is speech therapy not appropriate?

• Obligatory distortions (placement normal, anatomy not)

What surgery is for VPI?

Pharyngoplasty

What surgery is for cleft palate repair?

Palatoplasty

What surgery is for cleft lip repair?

Cheilorraphy