Transcript Cleft Palate and/or Velopharyngeal Dysfunction: Assessment

Cleft Palate and/or Velopharyngeal Dysfunction: Assessment and Treatment
Education Committee, ASHA Special Interest Division 5
Therapy Approaches-General goals
Purpose of this Poster
Effects of VPD on Resonance and Articulation
This poster will review assessment and therapeutic
approaches for working with children who demonstrate
speech disorders related to cleft palate and/or
velopharyngeal dysfunction. Methods for collaborating with
the interdisciplinary cleft palate/craniofacial team and
enhancing the ability to make differential diagnoses of
resonance versus articulation disorders will be included.
(These differ from patient to patient, one or several symptoms may be present)
especially on vowels and voiced oral consonants
Audible nasal air emission- audible emission of air stream through nasal cavity
during production of oral pressure consonants
Weak pressure consonants- reduced intraoral pressure on consonants
Shorter Utterance Length- breath support for speech is compromised due to air
leaking through nose as a result of VPD
Normal Velopharyngeal Function
Compensatory Articulation errors- inappropriate speech behaviors with faulty
-Closes off nasal cavity from oral cavity during speech
-Important for pressure sensitive sounds and normal
resonance
-Velopharyngeal closure accomplished by action of the
velum, lateral pharyngeal walls, and posterior pharyngeal
walls
Kummer (2001)
Velum at rest
Hypernasality- too much sound resonating in the nasal cavity during oral speech,
Velum during speech
Velopharyngeal Dysfunction (VPD)
-Failure of the velum, the lateral pharyngeal walls, and
posterior pharyngeal walls to achieve complete closure
during oral speech tasks
-Allows for the leakage of air and sound energy into the
nasal cavity during oral speech
Causes of VPD:
-Anatomical/structural defects known as velopharyngeal
insufficiency (Trost-Cardamone, 1989) e.g. cleft palate, submucous cleft
palate, short velum, deep pharynx, irregular adenoid, enlarged
tonsils
-Physiological /functional defects known as velopharyngeal
incompetence (Trost-Cardamone, 1989) e.g. poor muscle function,
paralysis, neuromuscular disorders
-Other causes known as velopharyngeal mislearning (Trost-Cardamone,
1989) e.g. learned behaviors, conversion disorder, stress-induced
velopharyngeal inadequacy, hearing loss, abnormal posterior or nasal
articulation, phoneme-specific nasal air emission
articulatory placement in an attempt to buildup oral pressure and airflow
Assessment of Speech Disorders associated with VPD
RESONANCE:
-SLP should judge resonance as normal, hypernasal, hyponasal or mixed.
-SLP should assess if nasal emission and nasal turbulence exist.
-Use connected speech, sentences with oral sounds, sentences with nasal
sounds, low pressure sentences, and high pressure phonemic contexts.
ARTICULATION:
-SLP should assess place and manner of production.
-SLP should assess for any compensatory articulation behaviors.
-Use single word productions and spontaneous speech
Additional techniques for assessing VPD:
Auditory detection: Using listening tubes, straws, stethoscope, nose plugging (Cul
de Sac test)
Tactile detection: Feeling the sides of nose for nasal turbulence
Visual detection: Using a mirror to observe nasal air emission
IMPORTANT: SLP must also monitor hearing acuity and middle ear disease for
potential effects on speech and language
**IF VPD IS SUSPECTED---ASSESSMENT USING PROCEDURES IN
CONJUNCTION WITH THE CLEFT PALATE/CRANIOFACIAL TEAM SLP
Nasometer- a microcomputer that analyzes
acoustic energy emitted through the oral cavity
and nasal cavity during the production of speech
Aerodynamic Assessment- measures oral pressure
and oral airflow during speech, capable of
estimating size of VP gap/orifice
To visualize velopharyngeal mechanism and function
Nasoendoscopy- using a flexible fiberoptic
nasopharyngoscope to view the nasal surface
of the velum and the velopharyngeal port during speech
Videofluoroscopy/Lateral Cephalographs
-radiographic procedures
to assess velopharyngeal closure during speech
-may eliminate compensatory errors, improve velopharyngeal function, and
decrease the perception of hypernasality
-target voiceless sounds before voiced (w, h, p, t, etc)
-use visual cues as needed
-start with sounds in isolation, then progress to syllables, words, phrases,
sentences
-use nasal occlusion to prevent development
of nasal snorting or fricatives
Kummer (2001)
2. Improve oral pressure/airflow, reduce nasal emissions,
and increase oral resonance
Voice disorders- hoarseness, breathiness, reduced volume, glottal fry
To assess function of velopharyngeal mechanism
1. Improve articulatory placement
-auditory feedback: listening tubes, straws, stethoscope
-tactile feedback: feeling the nose during oral and nasal speech
-visual feedback: using air paddles, See Scape, Nasometer
-increase articulatory effort: wider mouth opening,
Kummer (2001)
overarticulation, loudness
-increase awareness of oral and nasal airflow: negative practice,
description exercises
PLEASE KEEP IN MIND!!!!!
***SLPs work on changing articulation.
***Blowing, sucking, gagging, and oral motor exercises do NOT improve
velopharyngeal function for speech.
***Speech therapy is appropriate for teaching proper articulatory placement
prior to surgery for repair of a fistula or surgery to augment velopharyngeal
function.
***If no true progress is seen within 6-8 weeks of speech therapy—referral
back to Cleft Palate team for further assessment.
***Significant VPD may need to be managed physically.
Additional Resources
Contact: American Cleft Palate-Craniofacial Association
For SLP members and Cleft Palate-Craniofacial Teams
http://www.acpa-cpf.org/
Suggested References
Nasometer
Kummer (2001)
Nasoendoscopy
Kummer (2001)
Golding-Kushner, K.J. (2001). Therapy Techniques for Cleft Palate Speech and Related Disorders. San
Diego,CA: Singular.
Kummer, A. (2001). Cleft Palate and Craniofacial Anomalies: Effects on Speech and Resonance. Clifton
Park, NY: Thomson Delmar Learning.
Kummer, A. & Lee, L. (1996). Evaluation and Treatment of Resonance Disorders. LSHSS, 27, 271-281.
Peterson-Falzone, S.J., Hardin-Jones, M., & Karnell, M.P. (2001). Cleft Palate Speech, 3rd edition.
St. Louis, MO: Mosby.
Peterson-Falzone, S.J., Trost-Cardamone, J.E., Karnell, M.P. & Hardin-Jones, M. (2006). The
Clinician’s Guide to Treating Cleft Palate Speech. St. Louis, MO: Mosby Elsevier
Trost-Cardamone, J. (1989). Coming to terms with VPI: a response to Loney and Bloom. CPJ 26: 6870.
Acknowledgment
This poster presentation is the result of a collaborative effort on the part of the ASHA
Special Interest Division 5 Education Committee