MA Assessment and Treatment Aynsley Brian, Brittany Garay, Caroline Johnson, Sarah Williams and Melissa Gutierrez

Assessment All children with a history of a cleft or craniofacial are at risk for communication disorders Risk for communication disorders for a child with cleft of the primary palate is due to dental abnormalities. Cleft of the secondary palate puts the child at risk for the possibility of a fluctuation of hearing loss and VP dysfunction. These factors can cause problems in the areas of articulation, language, phonation and resonance at different times in development. Periodic assessments are needed due to the different times in development that a child with a cleft can experience communication issues.

Continuing Assessments Annual screenings with the craniofacial team is conducted until 4 years of age. The child should receive a speech- language evaluation around age 3. Perceptual and instrumental measures should be done prior to surgery to aid in improvement of speech and resonance afterwards. A post-op assessment should be done to determine the effect of surgery on speech and possible further need for intervention.

Diagnostic Interview Parent and family interview If possible, obtain information prior to the interview about the child’s medical and developmental history and parent’s current concerns about speech.

Possible Questions What concerns you about your child’s speech? What sounds does your child currently use? Does your child sound nasal to you? How does your child communicate? Was your child born with any congenital problems? Was your child quiet, average, or very vocal as an infant? Does your child have any difficulty chewing, sucking, or swallowing? Does your child snore at night? Has your child ever had a speech evaluation or speech therapy?

Language Screening Done throughout preschool years Done yearly at cleft palate team visits Can be done via parent questionnaire Observe the child and make note of their play behaviors, ability to request, follow commands, their spontaneous speech production, and repetition.

Speech Evaluation Formal articulation Tests Templin-Darley Tests of Articulation Bzoch Error Pattern Diagnostic Articulation Test Iowa Pressure Articulation test o Designed for assessing VP function o Tests are easy to use, however only assess children at the single word level

Informal Articulation Assessment Informal assessment of the child’s articulation at the sentence level provides better information about the child’s current functioning. Informal articulation assessment measures include syllable repetition and sentence repetition. Samples should contain many pressure sensitive consonants that are voiceless. To assess hypernasality, the sample should contain voiced oral sounds. To assess hyponasality, sentences should contain high frequency of nasal phonemes.

Assessing in connected speech Counting and rote speech could be used with children. Assessing the child during connected speech could be difficult, so have the child count or recite the alphabet. Hypernasality, articulation errors and nasal emissions are more apparent in connected speech.

What to evaluate? Articulation- important to identify the type and potential cause of errors and types of compensatory errors if present. o Stimulability- is the child stimulable to correct erred sound by merely changing placement? If so, this is a good prognostic factor for correction with speech therapy. o Nasal air emission- if present, determine the intensity, if there’s a rustle due to opening, or if a grimace is accompanied. o Consistency- how consistent are the errors or emissions.

What to evaluate? Phonation o Types and severity of dysphonia Oral motor dysfunction o Is apraxia of speech present? If so, should cause errors in valve closing for oral sounds. Resonance o Note whether normal, hyper, hypo, denasal, cul-de-sec or mixed o Determine type and severity

Low and no-tech evaluation procedures

Visual Detection Mirror test: o Mirror held under nose in order to evaluate nasal air emission Air paddle o Piece of paper is placed under the nose during speech tasks to determine if nasal air emission is present See scape o Nasal olive is placed in the child’s nose and is attached to a flexible tube that’s connected to a rigid vertical tube. o As the child repeats pressure-sensitive phonemes, a styrofoam stopper rises in the tube is there’s nasal emission.

Tactile detection Feeling the sides of the nose o Vibration can be felt from hypernasality

Auditory detection Nose pinch (cul-de-sac) o Done by having the child produce speech with nose occluded and unconcluded. o In normal speech, no difference in quality should be heard. Stethoscope o Drum of the stethoscope should be placed on either side of the nose. o Hypernasality can easily be heard through the stethoscope. Straw o Place one end of the straw in the child’s nose and the other end near the examiners ear o Can hear nasal emission Listening tube o A plastic tube that works like the straw and stethoscope o One end is placed in the nose and the other near the examiners ear to assess nasal emission

Differential Diagnosis Hypernasality and air emission can be caused by VPI, nasal fistula or articulation disorder Important to know the cause since it can have a direct impact on treatment recommendations o If oronasal fistula is present: Size and position can effect speech Compare anterior vs posterior sounds to determine if it’s symptomatic Close the fistula and compare occluded with unoccluded speech If hypernasality or nasal air emission is present, it’s important to determine if it’s cause is structural or due to misarticulation o Is it due to a nasal rustle? o Is it phoneme specific? o Is the child stimulable?

Follow-up Recommendations: o Treatment recommendations may be surgical, prosthetic management, or speech therapy o Discuss results with primary physician o Should be based on cause, severity, and type of disorder. Family counseling o Important outcome of the evaluation o Give handouts on useful information Evaluation report o Must be accurate, succinct, clear and concise

MA Recap 8 year old, 1 st grade student in regular classroom DiGeorge syndrome and Pierre Robin Sequalae Tracheomalacia o Tracheostomy tube secondary to tracheomalacia o 2 decannulations unsuccessful due to cyanotic Complete bilateral cleft – repaired at 12 months o Sucking and feeding problems Fed via Mickey tube until age 6 Expressive language: apraxia, severe nasality and past use of AAC device

Compensatory Errors with Pierre Robin Misarticulations that occur as response to velopharyngeal dysfunction Generalized backing Velar fricative Nasalization of oral consonants and vowels Nasal sniff and snort Pharyngeal plosive, fricative, affricate and nasal fricative Glottal stop Usually treated with speech therapy

Obligatory Errors with Pierre Robin Obligatory productions occur when articulation placement is normal but abnormal anatomy/physiology causes speech distortion Short utterance length Weak or omitted consonant sounds Changed rate and speech segment durations Nasalization of oral sound Requires surgical or prosthetic intervention for correction

Eliminating Misarticulations with Speech Therapy Educate child on anatomy and articulator placement Feedback o Visual: diagrams o Tactile: tongue blade, peanut butter o Auditory: contrasting nasal and non-nasal, Oral-Nasal Listener (or straw)

Eliminating Misarticulations with Speech Therapy Begin by training front sounds Plosives: bilabials and linguavelars Feedback: o Visual: mirror, yawn technique (to push the tongue down and the velum up) o Tactile: tongue blade o Auditory: open and close nose to contrast nasality

Eliminating Misarticulations through Speech Therapy Pharyngeal plosive substitutions Start with /ng/ and transition to /k,g/ Coordination of air pressure/release Feedback: o Tactile: spoon or tongue blade to suppress tongue tip, palpating throat

Eliminating Misarticulations through Speech Therapy Pharyngeal fricatives and affricates Feedback o Auditory: Straw (listening for airflow), alternate occluding nostrils Linguavelars (/t,d,n/) Feedback: o Tactile: biting tongue blade between incisors

Childhood Apraxia of Speech (CAS) Makes inconsistent sound errors Can understand language much better than he or she can talk Is hard to understand, especially for an unfamiliar listener Has difficulty imitating speech May appear to be groping when attempting to produce sounds or to coordinate the lips, tongue, and jaw for purposeful movement Has more difficulty saying longer words or phrases than shorter ones Speech may be affected by situational anxiety Sounds choppy, monotonous, or stresses the wrong syllable or word

Speech Therapy for CAS The focus of intervention for CAS is on improving the planning, sequencing, and coordination of muscle movements for speech production. Prosody training Imitate words and sentences of increasing length Getting feedback from a number of senses, such as tactile and visual cues (e.g., watching him/herself in the mirror) as well as auditory feedback Home exercise programs for maximum stimulation

Speech therapy for hypernasality and nasal emission Effective when the nasality is due to misarticulations Exception: residual hypernasality and/or nasal emission after VPI surgery and, occasionally hypernasality secondary to dysarthria Therapy techniques are the same for hypernasality and nasal emission.

Low-tech auditory feedback tools for hypernasality/ nasal emission Straw o Place 1 end at the entrance of the child’s nostril and the other end in his ear. Listening Tube o Used the same way as the straw Oral & Nasal Listener o A dual stethoscope with the end of a tube placed in the child’s nostril OR a funnel added to the end of the tube and placed in front of the child’s mouth

Low-tech visual feedback tools for hypernasality/ nasal emission cont’d Air Paddle o Paper paddle placed in front of mouth while producing pressure-sensitive phonemes with enough air pressure to force the air paddle to move See-Scape o While producing pressure-sensitive consonants, nasal olive placed in nostril that is attached to a flexible tube which is connected to a rigid plastic vertical tube containing a Styrofoam float

High-tech auditory feedback tools for hypernasality/ nasal emission Digital Recording Equipment o Audio recordings of normal and hypernasal speech used to help discriminate and self-evaluate

High-tech visual feedback tools for hypernasality/ nasal emission Nasometer o Reads sentences, aiming to keep nasality below the clinician-set threshold. Pressure-Flow Instrumentation o Pressure-flow is recorded to correct articulation errors that cause phoneme-specific nasal air emission. Nasopharyngoscopy o Allows direct visualization of the velopharyngeal movements in order to develop a degree of active control over the movements for opening/closing the valve

Tactile feedback for hypernasality/ nasal emission Raise velum up/down with tongue depressor while producing vowel sounds Lightly touch side of nose and face to feel vibration Yawn so that the posterior tongue is depressed and the velum is elevated in order to coarticulate the yawn with vowels and anterior consonant sounds

Tactile feedback for hypernasality/ nasal emission cont’d Increase volume Increase anterior mouth opening Pinch nostrils in order to feel increase in oral airflow and pressure

Phonation Dysphonia, impairment of any or one of the vocal organs, is common among people with VPI or craniofacial anomalies Characteristics of dysphonia: o Hoarseness o Breathiness o Glottal fry o Hard glottal attack o Inappropriate pitch level o Restricted pitch range o Displophonia (a condition where two sounds of a different pitch are produce simultaneously) o Inappropriate loudness

Phonation Dysphonia in patients with cleft palate most commonly due to: o Increased respiratory and muscular effort o Hyper-adduction of vocal folds while attempting to close the velopharyngeal valve The presence of dysphonia often masks nasality, making perceptual evaluation difficult Increased vocal effort may also increase VP function and decrease gap size for better resonance Should also note: o Quality of breath support o Type of breathing pattern o Ability to sustain phonation

MA History of tracheomalacia (weakness/floppiness of the tracheal walls) Underwent a tracheostomy and used a tracheostomy tube for respiration After attempts at decannulation, MA became cyanotic and had severe stridor (tracheotomy tube was replaced).

Techniques for Therapy Biofeedback-calls attention to automatic or unconscious physiological processes to manipulate with conscious control See-Scape- Aerodynamics-pressure-flow instrumentation o provides objective documentation of therapy progress

Phonation Pneumotachograph-real-time feedback measures: o Inspiratory volume o Maximum phonation volume To isolate inadequate respiratory support from velopharyngeal dysfunction, the clinician may plug the nostrils for one measurement then open them for the other Prolongation of voiceless continuants may also help discrimination between respiratory and velopharyngeal factors

Therapy Techniques continued Voice hygiene recommendations Inspiratory Muscle Training Holding breath for a certain time Phonating while pushing/pulling Pitch glides up and down