3.5 Evaluation Protocol Flashcards
What is the clinical paradigm?
3
- Listener judgement/perceptual analysis (client talks, we listen)
- Perceptual assessment leads to assumptions about anatomy and physiology
- Instrumental analysis should confirm perceptual judgement
Do we always use the clinical paradigm?
2
- No, sometimes perceptual measures and instrumental measures are divergent
- Need to use good clinical decision making skills and solid knowledge of anatomy and physiology
What is the evaluation protocol overview?
5
- Perceptual
- Oral examination
- Objective computer instruments
- Imaging
- Diagnostic therapy
In regards to the evaluation protocol, what components make up the perceptual part?
(2)
- Rating scales
- Clinical setting of VP closure
In regards to the evaluation protocol, what makes up the objective computer instruments?
(2)
- Nasometry
- Pressure flow
In regards to the evaluation protocol, what components make up the imaging part?
(4)
- Cephalometric radiographs
- Multiview Videofluoroscopy
- Fiberoptic Nasendoscopy
- Magnetic Resonance Imaging
In regards to the perceptual evaluation, the _______ and the ability to process and interpret what is heard becomes the most important assessment instrument.
Ear
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?
- Final arbiter
- Provide the standards
What are the methods for the perceptual assessment?
3
- Phonetic transcriptions
- Rating scales to quantify speech features (such as hypernasality, audible nasal air emission and/or nasal turbulence, and intelligibility)
- Qualitative descriptions
In regards to the perceptual evaluation, how do you evaluation resonance?
(3)
- Connected speech (spontaneous or reading)
- Use prolonged vowels
- Listen for nasal emission, weak consonants, compensatory errors
In regards to the perceptual evaluation, what do you need to determine when evaluating resonance?
(2)
- type of resonance (normal oral resonance, hypernasality, hyponasality, cul-de-sac resonance or mixed resonance)
- Severity (mild, moderate or severe)
In regards to the perceptual evaluation, what speech samples can be used?
(5)
- 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)
In regards to the perceptual evaluation, what do you need to determine when getting a speech sample?
(3)
- 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
In regards to the orafacial examination, what are the two parts?
(2)
- Cranial nerves and assessment of facial structures
- Oral exam
What tools are used during the orafacial exam?
4
gloves, flashlight, mirror, and tongue blade
What facial parts do you examine during the exam?
7
- 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)
What oral parts do you examine during the exam?
4
- 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?
Can you asses velopharyngeal function by only looking at the oral surface?
nope
What should you have the patient say instead of /ahhhhhhhh/?
/aaaaaaaaaah/ and have the patient stick the tongue out and down as far as possible
How should you evaluate oral motor function?
sequence speech with diadochokinetic (DDK) exercises (puh, tuh, kuh)
What judgments can be made during an oral exam?
2
- Symmetry of palate elevation
- Placement of velar dimple
What judgments cannot be made during an oral exam?
3
- Velopharyngeal closure
- Depth of Nasopharynx
- Pattern of closure
What do you look for during an oral exam?
7
- 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)
What do we need to know about the see-scape?
4
- Excellent to evaluate presence of nasal air escape
- Especially inaudible nasal air escape
- Note if it is consistent of inconsistent
- Nasal mirror
What are positive findings of a perceptual eval?
3
- Age-appropriate place of articulation
- Any oral pressure sounds
- Oral pressure with nasal occlusion
What are negative findings of a perceptual eval?
2
- Compensatory articulation
- No improvement in oral pressure with nasal occlusion
What are considerations for nasal congestion that can mask VPI?
(2)
- Test both nostrils for patency
- Decongest nostrils and reassess if necessary
What can hoarseness mask?
hypernasality
What might behavioral hypernasality be present?
“whinning” or child’s age
What are indirect instrumental assessments?
2
- Nasometry
- PERCI-SARS
What are the direct instrumental assessments?
4
- Nasoendoscopy
- Videofluoroscopy
- Radiography
- MRI
The nasometer analyzes __________ _________ emitted through the oral cavity and nasal cavity during the production of speech.
acoustic energy
The nasometer computes a ratio of the ___________ _________ acquired by the two microphones.
acoustic data
In regards to the nasometer, _______ is called nasalance (the acoustic correlate of perceived nasality) and is displayed as a percent.
ratio
Nasalance score can be compared to what?
normalative data
The PERCI-SARS uses what?
pressure transducers and flow transducers
The PERCI-SARS can be used to measure ___ ___________ and __________ during production of a small speech segment.
air pressure and airflow
PERCI-SARS gives an estimate velopharyngeal orifice size during what?
Speech production
What are the pros of PERCI-SARS?
2
- Excellent for research purposes
- Can evaluate effect of VPI on oral pressure
What are the cons of PERCI-SARS?
3
- Cost (over 10k)
- Limited to unvoiced bilabial plosives
- Cannot determine shape of VP port
What are the general rules of imaging?
If you’re going to image, you should be prepared to do something with the information
What are the purposes of imaging?
5
- 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
Videofluoroscopy uses what?
lateral, anterior-posterior, and base views to assess VP closure during speech
Videofluoroscopy studies are interpreted by who?
both a radiologist and a SLP
In regards to nasoendoscopy, view the nasal surface of the ________ and the _____________ _______ during speech.
- Velum
- Velopharyngeal port
Who can do a nasoendoscopy?
a speech language pathologist who is trained in the procedure
How should interpretation of the nasoendoscopy be done?
should be done by speech pathologist with input from the surgeon
What are the pros of a nasoendoscopy?
3
- In color, allows for direct visualization of VP mechanism
- Can rule out other pathologies
- Can determine size shape and opening of VP mechanism
What are the cons of nasoendoscopy?
- Patient compliance, must be verbal, age often a factor
In regards to radiography, the velar depth is what?
velar depth to length ratio = 2:3
What can radiography be completed?
produced during rest and sustained phonation
What can radiography determine?
can determine cranial base angle
In regards to a radiography, adenoid/tonsillar involution of what?
hypertrophy
What are we measuring with a MRI?
1+4
4 Basic Clinical Measures of Anatomical Function:
- Cranial Base Angle
- Length of Velum
- Thickness of Velum
- Depth of Pharynx
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)
VPI
Magnetic resonance Imaging can determine what?
submucous cleft palate
What is the protocol for magnetic resonance imaging?
5
- 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
In a recent review of patients receiving surgical correction, ___% did not have a cleft palate according to Riski et al.
29
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.
25
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.
50
The velopharyngeal mechanism consists of _______ and _______________ components
velar and pharyngeal
Oral exams allows observation only of what?
the oral side of the velum
Not seen on oral exam are what?
nasal surface of the velum, nasopharynx and pharyngeal walls
What two test are required to adequately view the VPI structures?
- Endoscopy
- Radiography
Screening velopharyngeal closure is what?
Simple and inexpensive
What do you want to ask parents in a quick screening?
4
- 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
What should you consider if you have the child say “buy baby a bab” or “popeye plays baseball” in a quick screening?
(2)
- If strong /b/ good indicator of velopharyngeal function
- If sounds hypernasal or /b/ sounds like /m/ –> refer
What should you consider if you have the child say “Mama made lemon jam” in a quick screening?
- If sounds “stuffy” may be indication of obstruction –> refer
What else should you screen for?
3
- Listen for oral pressure
- Use simple, inexpensive instruments
- Screen velopharyngeal closure
Delayed management of VPI leads to what?
- Increased failure of Speech/surgical intervention and refractory speech deficits
The rate of complete success when VPI is managed before 6 years of age is _____%?
90.9%
The success rate falls to _____% between 6 and 12 years?
73.9%
The success rate falls ______% between 12 and 18 years
70.0%
Success falls to ______ after 18 years
47.0%
In regards to management routes, in regards to surgery, lengthening the palate by retro-positioning the velum:
(3)
- V-Y pushback procedure
- Double-oppposing Z plasty
- Palatal re-repair
In regards to management routes, what are the two types of pharyngoplastiers:
- Pharyngeal flap
- Sphincterpharyngoplasty
In regards to management routes, what are the prosthetics?
2
- Palatal lift
- Obsturator
In regards to management routes, what is the therapeutic approach?
Speech therapy
What is a pharyngeal flap?
- Midline flap with lateral port control for breathing
Who are the candidates for a pharyngeal flap?
2
- Good pharyngeal port movement, especially medial movement of the lateral wall, but velum is still not making complete contact
- VP gap is larger (>4mm)
What are the possible complications of a pharyngeal flap?
- sleep apnea
- snoring
- Anesthesia complications
- Hyponasal resonance immediately post-operatively
What is a sphincter pharyngloplasty?
2
- Use lateral flaps created with the paltopharyngeus muscles to create permanent muscle pad on the posterior wall
- Creates a more narrow sphincter overall
Who are the candidates for a sphincter pharyngloplasty?
- those who have coronal/A-P or circular pattern with VP gap <4mm
What are the different types of protheses?
4
- Maxillary expander
- Palatal lift
- Palatal obturator
- Speech bulb
What does the maxillary expander do?
impact on fistula
What does the palatal lift do?
- elevates velum when there is poor velar movement
- dysarthria/stroke
What does the palatal obturator do?
covers any fistula/open cleft
What does the speech bulb do?
2
- Occludes nasopharynx
- Not as common in US
What are the considerations for a protheses?
4
- Prosthethes vs. Surgery
- Irritation/pain
- Infection
- Compliance = Biggest Issue we face
