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Documentation of Speech
Does a Problem Exist, and If So, How Severe Is
It?
It is not always clear to even the best-trained and most-specialized
clinicians when a problem exists. VPI that is severe and pervasive in its
impact on speech seldom leads to such uncertainty (Video 9-1
).
However, mild cases of VPI and marginal or borderline cases require
more scrutiny during the assessment process (Videos 9-2 and 9-3
). In
such cases instrumentation can help clarify an uncertain clinical speech
diagnosis, identify possible sources of subtle problems, and document
severity.
Has the Closure Status Condition Changed Over
Time?
Speech quality and intelligibility change over time in response to
growth, learning, or treatment. A major purpose of any instrumental
assessment is to take a “snapshot” that aempts to capture the
adequacy of the patient's VP function at a specific point in time. Such
snapshots, when taken at regular intervals, provide the most accurate
assessment of whether the child's VP speech closure is stable or whether
it is changing over time.
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How Instrumentation Contributes to
Management Decisions
Does the Instrumentation-Based Assessment
Support Physical or Behavioral Management?
When perceptual judgment suggests that intervention may be
warranted to improve speech, instrumentation can be useful to provide
supplemental evidence that intervention (speech therapy or physical
management) is or is not warranted. The results of instrumentationbased assessment can tip the balance of clinical decision making either
toward or away from intervention.
What Can the Instrumental Assessment Show Us or
Tell Us About the Type of Intervention That Should
Be Attempted?
A finding that the child's speech deviation or understandability is
consistent with VPI does not tell us what we should do about it. For
some children, speech therapy should be aempted first. For others,
some form of physical management, such as surgery or prosthetic
management, may be needed before speech therapy. Assessment of the
underlying anatomy and physiology is critical to our efforts to
determine not only what is wrong but what should be done to correct it.
Imaging studies such as videoendoscopy and videofluoroscopy are
commonly performed to obtain such information.
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Types of Instrumentation Used in the
Clinic
Instruments can be used with confidence for assessment and
management of speech disorders associated with VPI only after the
instruments have been carefully tested in the laboratory and the clinic
to determine that the quantifiable measurements they provide are stable
and repeatable (reliable) and that the measurements are meaningful
(valid). Some approaches have strong records of reliable, valid
performance. Others are still being tested.
Instrumentation must also be cost effective and clinically feasible.
Procedures that are expensive, difficult, and complex to complete may
not be worth pursuing, particularly if the information provided can be
obtained more easily and effectively with another approach. The
procedure also must be tolerable for the patient and should not interfere
with speech production. An assessment performed when speech
production is influenced by a patient's discomfort, fear, and emotion
may not provide valid information.
The instrumental assessment techniques described in the following
subsections have been shown to be reliable, valid, cost effective, and
clinically feasible when they are performed by or with the assistance of
an experienced, well-trained speech clinician.
A Caution About Imaging Studies
In some cases, a child may appear to have inconsistent ability to achieve
adequate VP closure for speech related to a phoneme-specific paern,
compensatory misarticulations (especially gloal stop or pharyngeal
fricative productions), or a VP mechanism that is physically not quite
normal. Phoneme-specific VPI and VPI associated with production of
compensatory articulations (described in earlier chapters) may be
modified by using appropriate therapy techniques. When mislearning is
involved, the child should be given the opportunity to benefit from
appropriate speech therapy, rather than being routed immediately
toward physical management. It is important that both the clinician
participating in the evaluation and the clinician providing the therapy
have a clear understanding of the nature of the error type and paern,
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its impact on VP closure, and the rationale for expecting improvement
from therapy. The clinician providing therapy may benefit from having
a copy of the videoendoscopic or videofluoroscopic speech examination
in addition to the wrien report describing the examination results.
Remember that a speaker who uses compensatory articulations may
actually have a velopharyngeal system capable of closure but is
essentially bypassing it to use old, habitual misarticulations. Therefore,
the learned behavior is affecting the amount of closure, rather than the
other way around.
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Instruments Used for Visualization of
the Velopharyngeal Mechanism
It is particularly helpful to view the VP mechanism during speech
production when making decisions about what surgical procedure or
what prosthetic management option is needed. The two most clinically
useful methods for seeing the VP mechanism during normal speech
production are videoendoscopy and videofluoroscopy. Both are types
of imaging studies that allow us to correlate what we see (VP closure
activity) with what we hear (perceived speech characteristics). This
correlation, in turn, helps confirm or modify the diagnostic hunches
derived from the perceptual speech assessment.
With regard to the function of the velopharyngeal system, the terms
“nasendoscopy” and “nasopharyngoscopy” are equivalent. Similarly,
“videoendoscopy,” “videonasendoscopy,” and
“videonasopharyngoscopy” are equivalent and place the emphasis on
the necessity of video recording of such examinations.
Videoendoscopic Speech Evaluation
Videoendoscopy employs a small (2.2- to 3.0-mm diameter) flexible
fiberoptic endoscope (Fig. 9-1), essentially a medical-grade periscope.
The endoscope is carefully inserted into one of the child's nasal
passages to view the nasal (dorsal) surface of the VP mechanism and
surrounding pharyngeal walls (Fig. 9-2). The endoscope is usually
coupled with video and audio recording equipment so that permanent
recordings may be replayed for later study, counseling, and future
comparative reference. As described in Chapter 5, videonasendoscopy
shows the action of the velum, the posterior pharyngeal wall, and the
lateral pharyngeal walls during speech (Fig. 9-3). Adenoid and palatine
tonsillar tissue, which may or may not influence VP closure, also may
be visible.
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FIGURE 9-1 A flexible fiberoptic endoscope.
FIGURE 9-2 A flexible fiberoptic endoscope placed for viewing the
velopharyngeal mechanism.
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FIGURE 9-3 Samples of endoscopic images of the velopharyngeal port in five
patients with varying degrees of closure. (From Karnell MP, Schultz K, Canady
JW: Investigations of a pressure-sensitive theory of marginal velopharyngeal
inadequacy. Cleft Palate Craniofac J 38: 346-357, 2001.)
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The success of videoendoscopy is influenced by a patient's maturity,
interest, and cooperation. A child may not be ready to participate in the
evaluation if he or she has had uncomfortable or otherwise negative
experiences with instrumental assessment. Anything that leads the
patient to bring preconceived negative expectations to the assessment
will unnecessarily complicate the process. Success also requires
appropriate equipment and procedures.
Whenever possible, the child's natural curiosity and interests can be
used to elicit cooperation during videoendoscopy. Depending on the
maturity of the child, it may be useful to use a sequence of images or
“cartoons” that help explain what we want to do and how we will do it.
The VP mechanism is introduced as a door that opens and closes when
we speak. The opening of the nasal passages is described as a cave with
a tunnel inside that leads to the door. The endoscope is described as a
periscope similar to that used by a submarine captain to see what is
above while diving underwater. We demonstrate for the child “tricks”
that the scope can do. We allow the child to look through the scope to
see what is on the other end. We explain that the scope can become a
“flashlight” by turning on the light source. Finally, we demonstrate how
the tip of the scope can be curved and straightened. We allow the child
to gently push the endoscope rocker arm while watching the tip of the
endoscope bend and straighten. After all this, the child has seen and
handled the scope.
Decades ago, the literature often described the velopharyngeal
mechanism as a “trap door.” That was before clinicians understood the
three-dimensional nature of the velopharyngeal mechanism. Thus, the
use of an analogy of a “door that opens and closes when we speak” is
an oversimplification, used only for the purpose of working with the
child.
The endoscope insertion tube must be smaller than the space through
which it must pass. Flexible endoscopes specifically designed for use
with children have very small insertion tubes and should easily pass
through a child's nasal passage. It is important to inspect both right and
left anterior nasal passages to determine which nasal passage may best
accommodate the insertion tube. Topical anesthetics may or may not be
necessary (Conlin and McLean, 2008, Chadha et al., 2013). They smell
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and taste bier, and the application process can be a source of irritation.
The anesthetic effect is only superficial and does not address the
sensation of pressure. A drop of surgical water-based lubricant carefully
applied near the tip of the insertion tube may help the scope pass easily.
It helps to have the child speak during insertion of the endoscope
through the nasal passages. By doing so, the child is occupied with
following directions and speaking rather than solely aending to what
is happening with the scope. We tell the child to count to 10 or repeat
funny phrases (e.g., “forty-four fat fish”). It may also help to have a
video monitor positioned so that the child can see the “trap door” when
it comes into view. Once inserted, the scope is positioned to provide the
best view of all the components of VP closure without causing the child
to be uncomfortable.
Clinicians who are very experienced in the use of videonasendoscopy
may be able to obtain good visualization of the velopharyngeal system
in young children without the use of a topical anesthetic. Because
children tend to become more and more anxious in proportion to the
number of steps in a procedure, these clinicians prefer not to administer
a vasoconstrictor and a topical anesthetic (often combined) before
introducing a pediatric scope into the nose, especially if the child
appears to have an open, clear route through the middle meatus.
However, other clinicians find that they do need to use a
vasoconstrictor-topical anesthetic first.
When used to understand VP closure activity, an endoscope is a tool
that is part of an assessment of speech. We are interested in not only the
appearance of the structures involved but also how they function
during speech. It helps to keep the child talking while the scope is in
place. The clinician must have in mind a series of well-designed ageappropriate speech samples for the child to produce. Sentences with no
nasal consonants and a high concentration of pressure consonants (e.g.,
“Look at this book with us”), sentences with no nasal consonants and
no pressure consonants (e.g., “You were away all year”), and sentences
with a high concentration of nasal consonants (“Mama made some
lemon jam”) provide the opportunity to view the VP mechanism during
production of oral pressure consonants, vowels, semivowels,
consonants, and transitions from one to another. Some clinicians use a
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modified version of the first paragraph of the Zoo Passage and Nasal
Sentences, which are commonly employed with nasometry (described
later). We also use “low pressure” sentences devoid of nasal and high
pressure consonants (Table 9-1). Using whispered speech, quiet voiced
speech, and loud speech helps demonstrate effects of variations in
speech effort. As noted earlier, recording video and audio allows for
replay useful for counseling the family and for consulting with the
surgeon or prosthodontist.
Sentences from the American English Sentence Sample (AESS), as
discussed Chapter 8, can also be used. The speech-language pathologist
will also want to tailor the speech stimuli to focus on specific paerns
identified in the perceptual speech assessment.
TABLE 9-1
Sentences Sets for Use During Acoustic Speech Recording and
Measurement of Nasalance*
HIGH PRESSURE ORAL
SENTENCES
NASAL SENTENCES
LOW PRESSURE ORAL
SENTENCES
Look at this book with us.
It's a story about a zoo.
That's where bears go.
Today it's very cold out of doors.
But we see a cloud overhead.
That's a prey white fluffy shape.
Mama made some lemon jam.
Ten men came when Jane rang.
Dan's gang changed my mind.
Ben can't plan on a long rain.
Amanda came from Bounding,
Maine.
You were away.
Where were you?
Why were you away?
You were away all year.
Will you wear a lily?
Roll a yellow wheel.
*
The high pressure sentences, modified from the Zoo Passage, are all oral phonemes
and include a high concentration of pressure consonants. The nasal sentences include
a high concentration of nasal consonants along with oral phonemes. The consonants
in the low pressure sentences are fully oral but do not require either complete VP
closure or a fully open VP port.
Videofluoroscopic Speech Evaluation
Videofluoroscopy is performed in a hospital department of diagnostic
radiology, where radiographs, or x-ray films, are obtained. However,
the team SLP should always be present to elicit the desired behavioral
sample, to keep an eye on the image and movements, and to make sure
that the examination is video recorded. The radiologist manages the
equipment, together with any needed support personnel. The images
may be thought of as “shadows” created when the child's oral and
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