1. DIAGNOSIS, EVALUATION AND THERAPY PLANNING FOR VELOPHARYNGEAL INSUFFICIENCY
Virginia Dixon-Wood, MA CCC-SLP
University of Florida Craniofacial Center
UF Speech and Hearing Clinic

2. 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

3. Insufficiency vs. Incompetency
Structurally based -cleft palate, submucous cleft
Motor based - stroke, cerebral palsy, low tone, TBI
Mix- VCFS (22q-)

4. 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

5. Birth to 6 months Feeding instruction and counseling
Speech and Language development
Hearing related issues

6. SPEECH COUNSELING Many children may never need speech therapy
Palate closure at 8-12 mo.
Six month speech evaluations
Parent counseling

7. 6 months- 1 year REEL Scale 2
Receptive-Expressive Emergent Language Scale – Bzoch
Birth to 3 years

8. 6 months – 1 year Discuss surgery (9-12 months) Parents expectations
Surgery counseling

9. 12 mo. - 2 years Begin phonological inventory range of sounds
oral/nasal contrast
REEL Scale – refer for EI
Parent counseling

10. Stages of Speech Development
Vocalizations - birth
Babbling - C+V repetition, 3 mo.
Jargon - mixed C+V, 8 mo.
First “true word” mo.
Two word combinations - 18 mo.

11. Early Speech Development
Cleft
m, n g
y, h, w
Non- cleft
m, n
d, b, p, g
y, w

12. 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

13. Early Speech Development
Sound differentiation
Nasal vs. Oral
bye-bye vs. mye mye
bye-bye vs. i i
bye-bye vs. ? ?

14. 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

15. Speech Characteristics of VPI
Glottal compensations
Nasal substitutions
Inappropriate nasal air emission
Weak pressure consonants
Hypernasality

16. Preschool Evaluation of VPI: Sound Production Audible nasal emission
Glottal Compensations

17. Perceptual testing Nasal emission Articulation Resonance
Intelligibility

18. Communicative Disorders Test Kenneth R.Bzoch
Designed for specific speech characteristics of cleft palate clients
Articulation
Resonance
Nasal emission
Voice - hoarseness, aspirate voice quality

19. 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/

20. 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

23. 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

24. Resonance Perceived during vowel production Cul-de-sac testing
Listener perception

25. 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

26. 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

27. Hypernasality Vowels with /b/
If resonance is normal (oral)- there should be no difference between the 2 productions
Base 10 index
Document change

29. Hyponasality Vowels with /m/
If normal resonance, there should be a difference (shift) between words
Base 10
Document change

30. Significance Indexes of 3/10 or greater
Do indexes match what you are hearing in conversational speech?
Impact on the child and/or family?

31. Voice Vowel prolongation- timed
Aspirate -may be compensation to conceal hypernasality
Hoarseness - may be caused by glottal compensations

32. 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

33. Speech Sample Spontaneous single words Conversation Estimate a %
Does it validate your other test results?

34. Palatal Fistulae Opening along the suture line Assess size (mm)
Document location
Can be responsible for abnormal articulation patterns
Nasal emission

35. Fistula Important part of oral exam
Anterior fistulae - impact on articulation
Nasal emission - may be inconsistent or phoneme specific
Resonance - may be normal

36. Fistula Recommendations based on speech results: surgical closure
obturate
do nothing

37. NOW WHAT ?

39. 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?

40. SPEECH THERAPY
WHAT?
WHY?
WHEN?
HOW?

42. 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

43. 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

44. What NOT to do Muscle Training: (Cole, 1979) Indirect Semidirect

45. 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

46. What NOT to do
McWilliams-no evidence that muscle training had any impact on improving speech or reducing nasal emission

47. Misarticulations Judy Trost-Cardamone, 1997
Obligatory errors - physical management
hypernasality, nasal emission, weak pressure consonants
Passive/Learned Errors -
compensatory errors, phoneme specific

48. Treatment Planning Child 1 Increase movement of articulators Vowels
Increase intelligibility /m,n,y,h,w,l/
Frication
Pressure sounds

49. Treatment Planning Child 2 Develop oral air flow Vowels
Increase intelligibility /m,n,y,h,w,l/
Frication
Pressure phonemes

50. Speech Therapy
Delayed speech development in young children but without glottal compensations
Nasal emission distortion/unintelligible speech
Poor articulatory movement

51. Speech Therapy Goal: Improve articulation/intelligibility
Hypernasality and nasal emission are not priorities
Improve movement of articulators
Accurate vowel production
Low pressure consonants

52. Speech Therapy Delayed speech development with glottal compensation
Improve intelligibility
Establish oral airflow - this is imperative
Can create “popping” or “clicking” for pressure sounds

53. Speech Therapy Child with glottal compensations:
Improve articulatory movements
Accurate vowels
Low pressure consonants - oral airflow
Frication
Plosives

54. Speech Therapy
Glottal compensations
Sonorants
Unvoiced
Final position

55. Speech Therapy
Glottal compensations-
Begin with ANTERIOR sounds

56. Speech Therapy Multisensory
Not successful at duplicating what they have heard
Visual
Tactile
Kinesthetic

57. Speech Therapy Glottal Articulation TEACHING PLACEMENT IS NOT ENOUGH
CAN CREATE CO-ARTICULATIONS

58. Palatal Fistula vs. VPI Obturate fistula Speech therapy - 3-6 months
Objective testing

59. VIDEOFLUOROSCOPY Poor candidates: compensatory articulation
poor articulation skills
significant palatal fistula
very young or uncooperative
child

60. 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