Assessment using “low-tech” and “no-tech” procedures

Assessment using “low-tech” and “no-tech” procedures
April 13, 2015

Direct versus indirect measures for evaluation
Direct information Visualize aspects of velopharyngeal function Videofluoroscopy Nasopharyngoscopy Wide spectrum of anatomic and physiologic causes for velopharyngeal dysfunction for appropriate and most effective treatment can be determined Although structures and function of the velopharyngeal valve can be seen through these measures the evaluation of what is seen is still subjective and open to interpretation

Direct versus indirect measures for evaluation
Indirect information Do not allow visualization of the structures Give objective data regarding the results of velopharyngeal function such as airflow, air pressure, or acoustic output The nasometer, and pressure/flow equipment are examples Advantage of objective data is that it can be compared to standardized norms for interpretation Can be used to collect objective data for pre and posttreatment comparisons Most important instrument is the human ear A determination can be made regarding the status of VP function and its potential for change In the perceptual evaluation the ear is used for to analyze product of VP function to make inferences about the adequacy of VP mechanism

Timetable for assessment
All children with a history of a cleft or craniofacial are at risk for communication disorders If the child has a cleft of the primary palate the risk is due to dental abnormalities If the cleft is related to the possibilities of a secondary palate the risk is related to the possibility of a fluctuation hearing loss and VP dysfunction Can cause problems in the areas in the area of articulation, language, phonation and resonance at different times in development Therefore periodic assessments are needed

First year Increased anxiety over what will happen in the future and the ultimate results of treatment Most people cope better with information rather than uncertainty Parents counseled by various professionals usually the cleft palate team members, soon after birth and again early in the first year Explain the diagnosis, the effect of anomalies on function, what might happen in the future, what will be done about it and the ultimate prognosis

Primary speech pathology concerns are feeding and prerequisites for verbal communication Counsel on speech language stimulation – under age 3 the emphasis should be on language development (quality of speech not as important as quantity) Instructions for sound stimulation after cleft repair are also provided

Annual screenings and periodic evaluations Until 4 years of age Annual craniofacial team meeting or visit Around age 3 the child should receive a comprehensive speech – language evaluation Evaluate resonance and velopharyngeal function if the child is using connected speech In addition, perceptual assessment along with instrumental measures should be done prior to surgery that is designed to improve speech and resonance A postoperative assessment should also be done to determine the effect of surgery on speech and whether further intervention is warranted

Diagnostic interview Valuable information from parent or family
Perceptual evaluation preceded by an interview with the patient or his family Send a pre-evaluation questionnaire to obtain medical and developmental history and current concerns about speech Prepare for the evaluation and can shorten the interview Parents are very good observers of their children Parents can compare the speech and language skills of their children with that of their peers and siblings If parents are worried about their child’s speech there probably is a good reason

Language screening At risk for language delay therefore need a language screening throughout the preschool years Done at yearly visits to the cleft palate team Concerns about language delay need to be addressed via a comprehensive language evaluation Also done if there are additional concerns such as hearing loss, developmental delay and/or neurological problems Done adequately in a clinic setting via a separate appointment and intervention started Screening can be done via parent questionnaire (give examples)

Language screening Observations of a child can also help and results compared to norms Observing play behaviors and type and complexity of gestures Asking the child to point to certain objects or follow certain commands Having interesting toys available and observing spontaneous vocalizations and utterances Listening to the child’s spontaneous speech while he or she is talking to the parent Asking questions or asking for explanations Having the child repeat sentences such as those listed in the articulation screening test Even while repeating the child may revert to his or her syntax and morphology

Formal language screening test
Tests for birth to three Receptive Expressive Emergent Language (REEL) The Early Language Milestone (ELM) Rossetti Infant-Toddler Language Scale Tests for 2 to 6 years Fluharty Preschool Speech and Language Screening Test Compton Speech and Language Screening Test

Speech evaluation When assessing articulation, resonance and velopharyngeal function it is important to select an appropriate speech sample to obtain the information Formal articulation tests To determine the cause of the speech problem (structure vs. function) Obtain data to develop an appropriate treatment plan Templin-Darley Tests of Articulation Bzoch Error Pattern Diagnostic Articulation Test Iowa Pressure Articulation test Designed for assessing VP function Easiest to use these tests however, normal speech does not contain single words Therefore informal test of articulation at the sentence length is more appropriate

Speech evaluation Informal test of articulation Syllable repetition
Test phonemes at the syllable level to isolate the effects of other sounds and to determine if there is a phoneme-specific nasal air emission Produce consonant phonemes (particularly plosives, fricatives, and affricates) in repetitive manner (e.g., pa, pa, pa, pee, pee, pee, ta, ta, ta, tee, tee, tee) Each of the pressure consonants should be tested with both a high and a low vowel sounds Helps to assess articulation and the presence of nasal emission on each individual phoneme Whether the nasality increases on high vowels than low vowel sounds

Speech evaluation Informal test of articulation Sentence repetition
Battery of sentences that test each consonant phoneme Sentences should contain phonemes that are similar in articulatory placement “take teddy to town” Quickly assess articulation, nasal emission and resonance in connected speech environment Much faster than a single-word articulation test and is actually a more valid test of normal speech production

Speech evaluation The sample should also contain many pressure sensitive consonants particularly those that are voiceless (e.g., sissy sees the sun in the sky) When testing for hypernasality the sample should contain a number of voiced oral sounds To separate out the effects of nasal air emission or compensatory errors the examiner should use a sample with a large number of low pressure consonants (how are you, where are you) To test for hyponasality the examiner should use sentences with a high frequency of nasal phonemes (my mama made lemonade for me) Ask either or questions when children are reluctant to talk

Speech samples Counting and rote speech
Connected speech can be difficult to obtain when evaluating young children Can be elicited by having the child count or recite the alphabet or count Counting from 60 to 70 or repeating 60, 60, 60, 60 Particularly informative because these numbers contain a combination of high vowels /i/, sibilants, plosives, and even a triple blend /kst/

Speech sample These sounds require a build up of and continuation of intraoral air pressure which can tax the VP mechanism and may overwhelm a VP valve Counting for 70 to 79 can also be diagnostic as this series contains a nasal phoneme followed by an alveolar plosive If there are timing difficulties then this becomes apparent in this speech sample as assimilated hypernasality Concerns regarding hyponasality can be assessed while counting from 90 to 99

Speech sample Spontaneous connected speech
Necessary to assess articulation and resonance in connected speech Connected speech increases the demands on the VP valving systems to achieve and maintain closure Hypernasality, articulation errors, and nasal emission more apparent Begin by asking questions that require short responses Either/or questions can be particularly helpful in getting the child to talk Once the child is responding questions that require a longer response can be asked (how do you play baseball?) If this fails encourage another family member to engage the child in conversation

What to evaluate Articulation
Important to identify the type of errors (compensatory, obligatory or just abnormal placement) Important to assess the potential cause of the errors (abnormal structure, apraxia, or oral-motor dysfunction, phonological disorder, delayed development or normal developmental error) Determine nasal emission during production of pressure sensitive phonemes or nasalization other oral consonants Necessary for development of an appropriate treatment plan

What to evaluate Obligatory error is one where the articulation placement is normal but the abnormality of the structure causes distortion of speech (placement the same for bilabial consonant /b/ and /m/ but the manner changes from oral to nasal due to a large VP opening) Voiced oral plosives result in the production of their nasal cognate Predominate use of nasal sounds in connected speech the examiner should suspect the presence of lack of VP closure due to obligatory errors

What to evaluate Articulation
Compensatory errors are common in persons with VPI Manner of articulation is maintained but the placement of production is moved posteriorly to the pharynx where there is airflow (substitutes a glottal plosive for a bilabial /p/ or a pharyngeal fricative for /s/) Glottal stop may be confused for an omitted sound Omitted sound has a smoother voice whereas a glottal stop is characterized by a quick sound and rapid onset time Vowel preceding the omitted sound is prolonged with increased laryngeal activity which can be felt by the examiner A pharyngeal fricative sounds similar to a lateral lisp can be differentiated by the presence of the airstream (in the oral cavity or the pharyngeal cavity) Cannot find the airstream at either side of the dental arch then the sound is pharyngeal

What to evaluate Stimulability
During the production of glottal stops there is less velopharyngeal movement than during the production of oral sounds Individuals use a posterior nasal fricative as a substitute for an /s/ sound also have velopharyngeal opening on a nasopharyngoscopy Due to faulty placement and not a valving disorder Child is usually stimulable for an elimination of nasal air emission If the child is able to produce the sound without nasal air emission or hypernasality merely by changing placement this suggests a good prognosis for correction with speech therapy

What to evaluate Nasal air emission
Assess for audible nasal air emission Necessary to determine whether it is low in intensity (due to a larger VP opening) Or if it is bubbly nasal rustle (turbulence) due to a small opening Nasal snort produced most often on /s/ blends Nasal grimace accompanies nasal emission and should be reported

What to evaluate Consistency should be reported as well
If nasal emission occurs during production of most pressure-sensitive phonemes it is considered consistent If it occurs occasionally on most pressure-sensitive phonemes then it is inconsistent If it occurs consistently on specific phonemes then it may be phoneme specific nasal emission (PSNAE) related to faulty articulation rather than VPI necessary to assess in connected speech Many people are able to achieve VP closure during short segments therefore nasal emission may not be noted during examination at the sentence level Because connected speech increases the demand on the VP mechanism nasal emission is more likely to be noted at this level

What to evaluate Weak consonants
Evaluated by listening to the force of production of the pressure-sensitive consonants Repeat sentences loaded with these consonants to test for oral pressure If they are weak in intensity and pressure it is assumed that intraoral pressure is compromised due to significant nasal air emission Weak consonants are usually associated with both nasal air emission and hypernasality due to a large VP opening

What to evaluate Short utterance length
Significant nasal air emission can also affect utterance length Determined by observing the phrasing of utterances in connected speech If the individual takes breaths frequently during speech this may be due to loss or air pressure through the VP valve and the need to replenish this air pressure Utterance length can be tested by asking the individual to count to 20 Most speakers count at least to 15 on one breath If more than two breaths are needed this may indicate a significant loss of air pressure during speech due to VP incompetence

What to evaluate Oral-motor dysfunction
Characteristics of VP dysfunction may occur as a result of apraxia of speech Individuals with apraxia have difficulty coordinating the movements of the various subsystems of speech including VP valve Causes errors in the closing of the valve for oral sounds and opening for nasal sounds Tends to increase with an increase in utterance length or phonemic complexity Note the difference in resonance between short simple utterances and longer phonemically complex utterances

What to evaluate Common in individuals with craniofacial syndromes (particularly with velocardiofacial syndrome – at risk for VPI and apraxia) Use formal tests for apraxia (nonspeech level to sentence level production) Repeat individual oral movements (e.g., lateralizing the tongue) Sequencing movements Diadockokinetic exercises Repeat words repetitively (e.g., patty cake, puppy dog, teddy bear, baby doll, kitty cat, bubble gum, basketball, peanut butter and jelly) If there is significant hypernasality the use of words with nasal sounds (e.g., money, mommy, many more) will help to isolate the oral motor dysfunction from the VPI

What to evaluate Resonance
Should be judged as either normal, hypernasal, hyponasal, denasal, cul-de-sac or mixed by listening to spontaneous speech If nasal sounds are heard more frequently than normal or if they are substituted for oral type sounds the resonance is hypernasal If oral-type sounds are heard as a substitution for nasal sounds the resonance is hyponasal Have the individual repeat sentences loaded with oral sounds and then repeat sentences loaded with nasal sounds if the type of resonance is hard to determine in spontaneous speech Cul-de-sac resonance sounds as if the voice is muffled and remains in the head Imitating hypernasal speech while closing the nose Mouth breathing or history of upper airway obstruction may suggest either hyponasality or cul-de-sac resonance

What to evaluate Resonance
Determining the type of resonance is important but determining the severity is usually irrelevant Severity does not impact treatment protocols Several authors have suggested the use of an equal-appearing interval scale with up to seven levels to rate the severity of deviant resonance Face validity but reliability is questionable More levels the less reliable the scale Use a single 4 point scale (normal, mild, moderate and severe) Hypernasality may be inconsistent Occur primarily on high vowels – reduces the oral resonance and increases transpalatal nasal resonance If the back of the tongue is too high during the production of high vowels there may be vowel specific hypernasality

What to evaluate Phonation
Dysphonia is common in individuals with VPI or craniofacial anomalies Listen for characteristics of dysphonia including hoarseness, breathiness, glottal fry, hard glottal attack, inappropriate pitch level, restricted pitch range, diplophonia or inappropriate loudness When present these abnormalities can be rated on a severity scale from mild to severe Ability to sustain phonation for 10 seconds or longer should be observed Dysphonic should be noted until the end of the prolonged vowel as the child begins to run out of air Quality of breath support and the type of breathing pattern should be noted

“low tech” and “no-tech” evaluation procedures
Experienced clinicians may be able to evaluate all of the above characteristics by merely listening to spontaneous speech or repetition of sentences This evaluation appears to be very reliable however less experienced clinicians may need supplemental tests

Visual detection Mirror test: a mirror can be held under the nares during speech in order to evaluate nasal air emission based on condensation Examiner places a mirror under the child’s nose during the production of pressure sensitive sounds If mirror clouds up it indicates nasal air emission Unfortunately this is not very practical technique because the mirror fogs as soon as the child breathes at the end of an utterance Shows nasal emission but there is no way to know if it was consistent or just occurred on one phoneme

Visual detection Air paddle The examiner can see nasal emission by using an “air paddle” as first described by Bzoch An “air paddle” can be cut from a piece of paper and placed underneath the nares during the production of repetitive syllables with pressure sensitive consonants (e.g., “pa, pa, pa, ta, ta, ta, ka, ka, ka) It is best to use voiceless consonants since these are consist of more air pressure therefore most likely to show nasal air emission If the paddle moves during the production of these sounds this indicates that there is nasal air emission

Visual detection See Scape Allows the examiner to view the occurrence of nasal air emission A nasal olive is placed in the child’s nostril The nasal olive is attached to a flexible tube that is connected to a rigid vertical tube As the child repeats pressure-sensitive phonemes a styrofoam stopper rises in the vertical tube if there is nasal emission At the end of an utterance the child will exhale slightly through the nose and the stopper will rise slightly at this point

Tactile detection Feeling the sides of the nose Vibration from hypernasality and nasal air emission can be felt by placing the index fingers lightly on the individual’s nose in the area of the cartilage The feeling can be simulated by prolonging /m/ and feeling the vibration of the nasal cartilage Auditory detection Visual and tactile detection is helpful But auditory detection is by far the best evaluation procedure These tests are more reliable

Auditory detection Nose pinch (cul-de-sac) The nose pinch test called the cul-de-sac test Done by having the child produce a speech segment with nose unoccluded and then repeat the same speech segment with the nostrils pinched closed To assess hypernasality the child is asked to prolong a vowel or repeat a sentence that is devoid of nasal consonants In normal speech there should be no perceptible difference in the quality of production of because nasal cavity is already closed by the VP valve If there is a dysfunctional VP valve the sound will resonate in the nasal cavity but be blocked by the closed causing cul-de-sac resonance

If the valve is functioning normally there should be no change in resonance with the closed nose A difference in quality with closure of the nares indicates hypernasality To assess for nasal air emission the child is asked to repeat syllables or sentences loaded pressure-sensitive consonants If there is an increase in oral pressure with closure of the nose this suggestive of significant nasal air emission To assess hyponasality the child is asked to produce a nasal sound repetitively (such as ma, ma, ma) If there is little or no difference in the quality of the speech with nose closed this suggests hyponasality

Auditory detection Stethoscope If a stethoscope is available, it is used to assess VP dysfunction The drum of the stethoscope can be placed on either side of nose or under the nose If there is hyper nasality or nasal emission during the production of oral sounds this can be clearly heard through the stethoscope The drum can be removed and the tubing placed at the entrance of one nostril Needs to be disinfected between patients

Auditory detection Straw Ultimate low-cost low-tech instrument Extremely helpful and reliable in detecting hypernasality and nasal emission Place the shorter end of the bending straw in the child’s nostril and the other end near the examiner’s ear Another use of the straw is detection of a lateral lisp which is often confused with nasal air emission The examiner can place a straw at different positions on the side of the dental arch during the production of a prolonged sibilant If air stream is lateralized it will be heard through the straw at the side of the dental arch rather than in the front

Auditory detection Listening tube A plastic tube works just like a stethoscope or the straw in helping to detect hypernasality and nasal emission One end of the straw is placed at the entrance to the child’s nostril and the other end is placed near the examiner’s ear as the child produces oral syllables or sentences The advantage is that you can make it any length for comfort The disadvantage is that the examiner needs to be careful to not to forget which end went in the child’s nose and which end went in his or her ear The tube needs to be either disinfected or discarded after use

Best way of evaluating hypernasality, nasal emission and velopharyngeal function Nasal emission can be heard in regular speech Nasal emission can be heard in noisy environment Slight inefficient closing can be heard as a click Risk for hypernasality with adenoid atrophy or maxillary advancement The examiner can determine when the nasal emission occurs and on what sounds Cheap equipment, reliable, dependable, and readily available Face validity – auditory assessment of an auditory even

Differential diagnosis of cause
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 If there is a oronasal fistula then the size of the fistula can determine the effect on speech If small it may not be symptomatic because the air flow in the oral cavity is horizontal to the opening If the fistula is 5 mm or more in diameter nasal emission may be noted with the production of pressure-sensitive consonants If the fistula is very large there may be hypernasality as well

The position of the fistula can also determine whether there is an effect on speech If the fistula is in the area of the incisive foramen (common) there may be nasal air emission during the production of lingual-alveolar sounds when the tongue pushes air into the opening as it elevates for production A midpalatal fistula can result in the use of a palatal-dorsal placement for many sounds as a compensatory strategy for closing the fistula with the tongue A posterior fistula may be less symptomatic because there are few posterior sounds to force the air stream upward

Differential diagnosis of the cause
To determine if the fistula is symptomatic compare the occurrence of nasal air emission on anterior sounds vs. posterior sounds If there is no difference then the source of the nasal air emission is probably the VP valve If there is more nasal emission on the anterior than on the posterior sounds then this suggests the fistula is the cause Close the fistula temporarily with chewing gum or fruit rollup, dry the area with a Q-tip and then compare the speech with and without occlusion A reduction in nasal air emission or hypernasality are still noted with total occlusion of the fistula then VPI is implicated

Differential diagnosis of the cause
One complication in evaluating the effect of VPI in the presence of a fistula is the combined effect of the two When there is a leak in the system as a result of a fistula this can cause the VP mechanism to function less efficiently Unless the fistula is obturated or closed it can be difficult to evaluate the capabilities of VP mechanism Use a multidisciplinary approach

When there is hypernasality or nasal air emission it is necessary to determine if the cause is structural or due to misarticulation A nasal rustle commonly occurs due to a small VP opening (structural cause - surgery) It can also occur due to the production of a posterior velar fricative (mislearning – speech therapy) Assess the consistency of the occurrence and stimulability

If it is phoneme specific (occurs only certain sounds –particularly sibilants) this is due to misarticulation If it is phoneme specific in that it occurs on high vowels /i/ this can be faulty articulation as well Stimulability testing is very helpful in making a correct diagnosis If nasal air emission or hypernasality are eliminated with a change in articulation placement this confirms that the cause is faulty articulation and not VPI

Follow-up Recommendations
Nasal air emission and hypernasality – large VPI gap – requires surgery Nasal rustle that is phoneme specific or if there are articulation errors that are not obligatory, speech therapy is suggested Additional assessments may be recommended Sleep study, videofluoroscopic or endoscopic evaluation of a swallow Treatment recommendations may include surgical or prosthetic management or speech therapy Always discuss results with referring or primary physician

Follow-up Recommendations should always be based on
the cause and severity of the speech or resonance disorder, its effect on the child’s quality of life, the potential for improvement, the associated risks and the desires of the child and family Careful not to impose the examiner’s own value system on the child and the family

Follow-up Family counseling
Counseling the family (and the child if appropriate) is one the most important outcomes of the evaluation Handouts with labeled drawings are useful in helping the family understand the anatomy, problem with speech and any surgical procedures Available online at Cleft Palate Foundation or the American Cleft Palate – Craniofacial Association Evaluation report Standardized form available from American Cleft Palate – Craniofacial Association Great variability between centers when evaluation results are reported Must be accurate, succinct, clear and concise

Follow-up Fail to consider their customers when writing the report
Long reports are usually not read and are definitely not appreciated by other busy professionals Appropriate language and medical terminology must be used that can be understood by the readers Diacritic symbols are not understood by nonprofessionals Letters or word descriptions must be used along with the symbols Focus on the evaluation results, the examiner’s impressions and recommendations Be confident and correct in stated conclusions and recommendations – impacts surgical management

Assessment using “low-tech” and “no-tech” procedures

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Assessment using “low-tech” and “no-tech” procedures

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