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ECU Craniofacial Anomalies + Laryngeal Rehab > 3.5 Evaluation Protocol > Flashcards

3.5 Evaluation Protocol Flashcards

1
Q

What is the clinical paradigm?

3

A
  1. Listener judgement/perceptual analysis (client talks, we listen)
  2. Perceptual assessment leads to assumptions about anatomy and physiology
  3. Instrumental analysis should confirm perceptual judgement
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2
Q

Do we always use the clinical paradigm?

2

A
  • No, sometimes perceptual measures and instrumental measures are divergent
  • Need to use good clinical decision making skills and solid knowledge of anatomy and physiology
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3
Q

What is the evaluation protocol overview?

5

A
  • Perceptual
  • Oral examination
  • Objective computer instruments
  • Imaging
  • Diagnostic therapy
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4
Q

In regards to the evaluation protocol, what components make up the perceptual part?

(2)

A
  • Rating scales

- Clinical setting of VP closure

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5
Q

In regards to the evaluation protocol, what makes up the objective computer instruments?

(2)

A
  • Nasometry

- Pressure flow

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6
Q

In regards to the evaluation protocol, what components make up the imaging part?

(4)

A
  • Cephalometric radiographs
  • Multiview Videofluoroscopy
  • Fiberoptic Nasendoscopy
  • Magnetic Resonance Imaging
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7
Q

In regards to the perceptual evaluation, the _______ and the ability to process and interpret what is heard becomes the most important assessment instrument.

A

Ear

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8
Q

In regards to the perceptual evaluation, auditory perceptual judgments are typically the _______ ________ in clinical decision-making and often __________ ______ ___________ against which instruments (objective) measures are evaluated?

A
  • Final arbiter

- Provide the standards

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9
Q

What are the methods for the perceptual assessment?

3

A
  • Phonetic transcriptions
  • Rating scales to quantify speech features (such as hypernasality, audible nasal air emission and/or nasal turbulence, and intelligibility)
  • Qualitative descriptions
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10
Q

In regards to the perceptual evaluation, how do you evaluation resonance?

(3)

A
  • Connected speech (spontaneous or reading)
  • Use prolonged vowels
  • Listen for nasal emission, weak consonants, compensatory errors
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11
Q

In regards to the perceptual evaluation, what do you need to determine when evaluating resonance?

(2)

A
  • type of resonance (normal oral resonance, hypernasality, hyponasality, cul-de-sac resonance or mixed resonance)
  • Severity (mild, moderate or severe)
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12
Q

In regards to the perceptual evaluation, what speech samples can be used?

(5)

A
  • Articulation test or screening of consonants
  • Repetition of pressure-sensitive phonemes (pa, pa, pa, etc.)
  • Repetition of sentences that are loaded with pressure-sensitive phonemes
  • Counting from 60-70 (hypernasality)
  • Counting from 90-100 (hyponasality)
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13
Q

In regards to the perceptual evaluation, what do you need to determine when getting a speech sample?

(3)

A
  • Presence and type of nasal emission (unobstructed or obstructed)
  • Consistency of nasal emission and whether it is phoneme-specific
  • Effect on pressure consonants and utterance length
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14
Q

In regards to the orafacial examination, what are the two parts?

(2)

A
  • Cranial nerves and assessment of facial structures

- Oral exam

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15
Q

What tools are used during the orafacial exam?

4

A

gloves, flashlight, mirror, and tongue blade

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16
Q

What facial parts do you examine during the exam?

7

A
  • Lips
    • Movement sufficient for speech production (i-oo)
  • Eyes
    • Hypo/hypertelorism
    • Epicanthal folds
  • Ears: Microtia, anotia, atresia
  • Nose/airway
    • look at patency of each nostril
  • Maxilla
    • micro/macrognathia, micro/macrostomia
  • Dentition
  • Tongue
    • Ankyloglossia (tongue tie)
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17
Q

What oral parts do you examine during the exam?

4

A
  • Hard palate
    • vault: low or high
    • Fistula
    • Any devices (could impact speech)
  • Velum/uvula
    • Bifid uvula, zona pellucida
    • Length of velum
    • Mobility of velum (“ahh”: ah…ah…ah)
  • Pharynx
    • Movement of lateral and posterior pharyngeal walls
    • Passavant’s ridge
  • Tonsils
    • Enlarged?
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18
Q

Can you asses velopharyngeal function by only looking at the oral surface?

A

nope

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19
Q

What should you have the patient say instead of /ahhhhhhhh/?

A

/aaaaaaaaaah/ and have the patient stick the tongue out and down as far as possible

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20
Q

How should you evaluate oral motor function?

A

sequence speech with diadochokinetic (DDK) exercises (puh, tuh, kuh)

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21
Q

What judgments can be made during an oral exam?

2

A
  • Symmetry of palate elevation

- Placement of velar dimple

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22
Q

What judgments cannot be made during an oral exam?

3

A
  • Velopharyngeal closure
  • Depth of Nasopharynx
  • Pattern of closure
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23
Q

What do you look for during an oral exam?

7

A
  • Presence of an oronasal fistula (if there is a history of cleft palate)
  • Stigmata of a submucous cleft (if there is no history of cleft palate)
  • Velar length and mobility during phonation
  • Position of uvula during phonation (skewed indicates either enlarged tonsil or unilateral paralysis /paresis)
  • Enlarged tonsils
  • Dental or occlusal abnormalities
  • Sign of oral-motor dysfunction (particularly if patient is syndromic)
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24
Q

What do we need to know about the see-scape?

4

A
  • Excellent to evaluate presence of nasal air escape
  • Especially inaudible nasal air escape
  • Note if it is consistent of inconsistent
  • Nasal mirror
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25
Q

What are positive findings of a perceptual eval?

3

A
  • Age-appropriate place of articulation
  • Any oral pressure sounds
  • Oral pressure with nasal occlusion
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26
Q

What are negative findings of a perceptual eval?

2

A
  • Compensatory articulation

- No improvement in oral pressure with nasal occlusion

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27
Q

What are considerations for nasal congestion that can mask VPI?

(2)

A
  • Test both nostrils for patency

- Decongest nostrils and reassess if necessary

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28
Q

What can hoarseness mask?

A

hypernasality

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29
Q

What might behavioral hypernasality be present?

A

“whinning” or child’s age

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30
Q

What are indirect instrumental assessments?

2

A
  • Nasometry

- PERCI-SARS

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31
Q

What are the direct instrumental assessments?

4

A
  • Nasoendoscopy
  • Videofluoroscopy
  • Radiography
  • MRI
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32
Q

The nasometer analyzes __________ _________ emitted through the oral cavity and nasal cavity during the production of speech.

A

acoustic energy

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33
Q

The nasometer computes a ratio of the ___________ _________ acquired by the two microphones.

A

acoustic data

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34
Q

In regards to the nasometer, _______ is called nasalance (the acoustic correlate of perceived nasality) and is displayed as a percent.

A

ratio

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35
Q

Nasalance score can be compared to what?

A

normalative data

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36
Q

The PERCI-SARS uses what?

A

pressure transducers and flow transducers

37
Q

The PERCI-SARS can be used to measure ___ ___________ and __________ during production of a small speech segment.

A

air pressure and airflow

38
Q

PERCI-SARS gives an estimate velopharyngeal orifice size during what?

A

Speech production

39
Q

What are the pros of PERCI-SARS?

2

A
  • Excellent for research purposes

- Can evaluate effect of VPI on oral pressure

40
Q

What are the cons of PERCI-SARS?

3

A
  • Cost (over 10k)
  • Limited to unvoiced bilabial plosives
  • Cannot determine shape of VP port
41
Q

What are the general rules of imaging?

A

If you’re going to image, you should be prepared to do something with the information

42
Q

What are the purposes of imaging?

5

A
  • Identify presence of velopharyngeal gap
  • Determine size of VP gap
  • Determine location of VP gap
  • Identify structures of VP mechanism that contribute to closure (patterns of closure: sagittal, coronal, circular, passavant’s ridge)
  • Establish consistency of VP movement and/or VP gap
43
Q

Videofluoroscopy uses what?

A

lateral, anterior-posterior, and base views to assess VP closure during speech

44
Q

Videofluoroscopy studies are interpreted by who?

A

both a radiologist and a SLP

45
Q

In regards to nasoendoscopy, view the nasal surface of the ________ and the _____________ _______ during speech.

A
  • Velum

- Velopharyngeal port

46
Q

Who can do a nasoendoscopy?

A

a speech language pathologist who is trained in the procedure

47
Q

How should interpretation of the nasoendoscopy be done?

A

should be done by speech pathologist with input from the surgeon

48
Q

What are the pros of a nasoendoscopy?

3

A
  • In color, allows for direct visualization of VP mechanism
  • Can rule out other pathologies
  • Can determine size shape and opening of VP mechanism
49
Q

What are the cons of nasoendoscopy?

A
  • Patient compliance, must be verbal, age often a factor
50
Q

In regards to radiography, the velar depth is what?

A

velar depth to length ratio = 2:3

51
Q

What can radiography be completed?

A

produced during rest and sustained phonation

52
Q

What can radiography determine?

A

can determine cranial base angle

53
Q

In regards to a radiography, adenoid/tonsillar involution of what?

A

hypertrophy

54
Q

What are we measuring with a MRI?

1+4

A

4 Basic Clinical Measures of Anatomical Function:

  • Cranial Base Angle
  • Length of Velum
  • Thickness of Velum
  • Depth of Pharynx
55
Q

Use a magnetic resonance imaging (MRI) when you suspect _______ (post surgery) is due to attachment of levator fibers to hard palate (confirm with other methods)

A

VPI

56
Q

Magnetic resonance Imaging can determine what?

A

submucous cleft palate

57
Q

What is the protocol for magnetic resonance imaging?

5

A
  • whole head scan
    • Identify midsagittal image
    • Create anatomical section scan for oblique with attention to the angle of the muscle
    • 2D oblique coronal and axial scans
    • 3D sometime available
58
Q

In a recent review of patients receiving surgical correction, ___% did not have a cleft palate according to Riski et al.

A

29

59
Q

In a recent review of patients receiving surgical correction, ____% did not have a cleft palate according to Losken A, Williams JK, Burstein FD, Malick D, and Riski JE.

A

25

60
Q

In a recent review of patients receiving surgical correction, ____% of hypernasal patients diagnosed with 22q11.2 deletion (velo-cardio-facial syndrome) did not have an overt cleft palate.

A

50

61
Q

The velopharyngeal mechanism consists of _______ and _______________ components

A

velar and pharyngeal

62
Q

Oral exams allows observation only of what?

A

the oral side of the velum

63
Q

Not seen on oral exam are what?

A

nasal surface of the velum, nasopharynx and pharyngeal walls

64
Q

What two test are required to adequately view the VPI structures?

A
  • Endoscopy

- Radiography

65
Q

Screening velopharyngeal closure is what?

A

Simple and inexpensive

66
Q

What do you want to ask parents in a quick screening?

4

A
  • Do /p/ and /b/ sound like /m/?
  • Does “dada” come out sounding like “nana”
  • Can child say “papa” or “baba”
  • Can child blow and produce oral airflow
67
Q

What should you consider if you have the child say “buy baby a bab” or “popeye plays baseball” in a quick screening?

(2)

A
  • If strong /b/ good indicator of velopharyngeal function

- If sounds hypernasal or /b/ sounds like /m/ –> refer

68
Q

What should you consider if you have the child say “Mama made lemon jam” in a quick screening?

A
  • If sounds “stuffy” may be indication of obstruction –> refer
69
Q

What else should you screen for?

3

A
  • Listen for oral pressure
  • Use simple, inexpensive instruments
  • Screen velopharyngeal closure
70
Q

Delayed management of VPI leads to what?

A
  • Increased failure of Speech/surgical intervention and refractory speech deficits
71
Q

The rate of complete success when VPI is managed before 6 years of age is _____%?

A

90.9%

72
Q

The success rate falls to _____% between 6 and 12 years?

A

73.9%

73
Q

The success rate falls ______% between 12 and 18 years

A

70.0%

74
Q

Success falls to ______ after 18 years

A

47.0%

75
Q

In regards to management routes, in regards to surgery, lengthening the palate by retro-positioning the velum:

(3)

A
  • V-Y pushback procedure
  • Double-oppposing Z plasty
  • Palatal re-repair
76
Q

In regards to management routes, what are the two types of pharyngoplastiers:

A
  • Pharyngeal flap

- Sphincterpharyngoplasty

77
Q

In regards to management routes, what are the prosthetics?

2

A
  • Palatal lift

- Obsturator

78
Q

In regards to management routes, what is the therapeutic approach?

A

Speech therapy

79
Q

What is a pharyngeal flap?

A
  • Midline flap with lateral port control for breathing
80
Q

Who are the candidates for a pharyngeal flap?

2

A
  • Good pharyngeal port movement, especially medial movement of the lateral wall, but velum is still not making complete contact
  • VP gap is larger (>4mm)
81
Q

What are the possible complications of a pharyngeal flap?

A
  • sleep apnea
  • snoring
  • Anesthesia complications
  • Hyponasal resonance immediately post-operatively
82
Q

What is a sphincter pharyngloplasty?

2

A
  • Use lateral flaps created with the paltopharyngeus muscles to create permanent muscle pad on the posterior wall
  • Creates a more narrow sphincter overall
83
Q

Who are the candidates for a sphincter pharyngloplasty?

A
  • those who have coronal/A-P or circular pattern with VP gap <4mm
84
Q

What are the different types of protheses?

4

A
  • Maxillary expander
  • Palatal lift
  • Palatal obturator
  • Speech bulb
85
Q

What does the maxillary expander do?

A

impact on fistula

86
Q

What does the palatal lift do?

A
  • elevates velum when there is poor velar movement

- dysarthria/stroke

87
Q

What does the palatal obturator do?

A

covers any fistula/open cleft

88
Q

What does the speech bulb do?

2

A
  • Occludes nasopharynx

- Not as common in US

89
Q

What are the considerations for a protheses?

4

A
  • Prosthethes vs. Surgery
  • Irritation/pain
  • Infection
  • Compliance = Biggest Issue we face

ECU Craniofacial Anomalies + Laryngeal Rehab (35 decks)

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