DIAGNOSIS, EVALUATION AND THERAPY PLANNING FOR VELOPHARYNGEAL

INSUFFICIENCY

Virginia Dixon-Wood, MA CCC-SLPUniversity 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

• Non- cleft• m, n • d, b, p, g• y, w

• Cleft• m, n• g• y, h, 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 Characteristicsof 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• Direct

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