DIAGNOSIS, EVALUATION AND THERAPY PLANNING FOR VELOPHARYNGEAL INSUFFICIENCY Virginia Dixon-Wood, MA...
-
Upload
cassandra-fleming -
Category
Documents
-
view
215 -
download
0
Transcript of DIAGNOSIS, EVALUATION AND THERAPY PLANNING FOR VELOPHARYNGEAL INSUFFICIENCY Virginia Dixon-Wood, MA...
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
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.
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
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
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
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?
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
• 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
• 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
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