1 Evaluation of Velopharyngeal InsufficiencyMelissa Montiel, MS, CCC-SLP Speech Pathologist

2 Financial Disclosure Financial Disclosure: I am receiving an honorarium from the South Carolina Speech Language Hearing Association for this presentation and is employed by MUSC. Non Financial Disclosure: No relevant non-financial relationships to disclose.

3 VPI defined Velopharyngeal Insufficiency: “An anatomical or structural defect that precludes adequate velopharyngeal closure (the decoupling of the oral and nasal cavities) ”* Basically, one is unable to appropriately and/or fully close off your oropharynx from the nasopharynx for the purpose of speech/swallowing

4 Common causes/syndromes of VPIHistory of cleft palate Submucous cleft palate 22q11 deletion (VCFS, DiGeorge Syndrome) Pierre Robin Sequence Treacher Collins Neurological impairment (CP,dysarthria) Adenoid removal Severe sensorineural hearing loss, especially congenital Idiopathic-sometimes these children may have no significant medical hx. Cervical spine anomalies (excessive nasopharyngeal depth)

5 Common signs of VPI Poor feeding/sucking as an infantLiquid coming through the nose Severe articulation deficits, specifically weak pressure consonants.

6 Signs Con’t Difficulty blowing bubbles/birthday candles/sucking through a straw Nasal “snorting” or turbulence consistent throughout connected speech Speech sounds as if there is too much sound in the nose (hypernasality)

7 Voice vs. resonance Voice describes phonation and is a function of the larynx Terms may be “harsh, weak,hoarse, breathy” Associated with nodules, cysts, polyps and other laryngeal pathology

8 Resonance Resonance is a function of the velopharyngeal mechanism and is a property of vowels Associated terms: hypernasality, hyponasality, mixed or “cul-de-sac”

9 Voice Vs. Resonance

10 Resonance: Hypernasality-too muchTerm associated with VPI Hypernasality is too much energy resonating in the nasal cavity. Nasality describes energy. Vowels are energy. We are using the term hypernasal to describe a vowel.

11 Resonance: What about the consonant?Most consonants have pressure, so you are listening for a nasal air emission (NAE), which sounds like snorting Can also perceive weak pressure on phonemes (m/b, n/d)

12 Resonance: Sounds like VPIHypernasality Nasal air emissions Weak pressure consonants Nasal grimacing

13 Resonance: HyponasalityNot used to describe VPI Hyponasality is not enough energy resonating in the nasal cavity. (Ex, enlarged adenoids, allergies). The patient may sound as if they are “stuffed up” or have a cold Hyponasality is perceived on nasal phonemes (/m,n,ing/) “Mamma made muffins”

14 Resonance: mixed or “cul-da-sac”A pt with VPI and enlarged tonsils/adenoids Large adenoids preventing proper closure VPI with anterior blockage Behavioral

15 Perceptual effects on resonance of a high pitched voiceVoice Meet Resonance Perceptual effects on resonance of a high pitched voice Hyponasality and “deep voice” Low vocal volume and VPI

16 Hypernasality-good artic

17 Hypernasality-good artic

18 Hypernasal-good articulation

19 Hyponasal

20 Hyponasality

21 VPI assessment- What’s the PurposeStructure vs Function

22 VPI Assessment Perceptual Manometry Nasendoscopy

23 VPI Assessment-PerceptualPerceptual evaluation: Speech production (articulation) Resonance Nasal air emissions

24 VPI Assessment Nasometry Measures resonant energyMicrophone measures nasal vs. oral energy Objective findings are compared against normative data

26 Testing example Prolonged Sounds Norms S.D. Score (mean) RangeProlonged /a/ 6 3 Text Entry Text Entry Prolonged /i/ Text Entry Text Entry Prolonged /s/ 0 0 Text Entry Text Entry Prolonged /m/ Text Entry Text Entry Oral Passages Norms S.D. Score (mean) Range Bilabial Plosives Text Entry Text Entry Alveolar Plosives Text Entry Text Entry Velar Plosives Text Entry Text Entry Sibilant Fricatives Text Entry Text Entry

27 Actual test sample Prolonged Sounds Norms S.D. Score (mean) Standard Deviation from Mean Prolonged /a/ Prolonged /i/ Prolonged /s/ Prolonged /m/ Oral Passages Norms S.D. Score (mean) Standard Deviation from Mean Bilabial Plosives Lingual-Alv Plosives Velar Plosives Sibilant Fricatives

28 Oral Passages Bilabial Plosives-Pick up a book, pick up a pie, pick up a baby Lingual-Alveolar Plosives -Take a tire, take a turtle, take a teddy Velar Plosives -Go get a cookie, go get a car, go get a cake Sibilant Fricatives -Susie sees the dress, Susie sees the scissors, Susie sees the horse

29 -Mama made muffins, mama made mittens, mama made lemonadeOral Passage cont’d Nasals -Mama made muffins, mama made mittens, mama made lemonade

30 Pt. example-PSNAE /s/ phonemeOral Passages Norms S.D. Score (mean) Standard Deviation from Mean Bilabial Plosives Lingual-Alv Plosives Velar Plosives Sibilant Fricatives

31 Phoneme Specific Nasal Air EmissionDeficit in which the patient is able to achieve complete closure of VP port, however s/he has developed production of specific phonemes with nasal rather than oral pressure/flow/turbulence Deficit is an error in articulation, not the VP mechanism Generally occurs with sibilants and affricates. Can be very misleading to the lay listener

32 VPI Assessment Perci Sar Provide pressure/flow informationEstimates the area of the VP gap during pressure consonant production

34 VPI Assessment-NasendoscopyDirect visualization of the VP mechanism during speech Provide information regarding closure pattern Assessment of related areas – tonsils, adenoids, and vocal cords

35 Closure patterns Coronal: Palatal, front to back movement (A)Sagittal: Lateral wall closure (B) Circular: Combination of coronal and sagittal (C) Circular with Passavant’s ridge: Lateral wall, posterior and anterior movement (D)

36 Movement

37 Normal closure

44 Roll of an anterior fistula Wide VPI vs small gap and perceptualSide notes Roll of an anterior fistula Wide VPI vs small gap and perceptual

45 VPI correction Adenoidectomy, Palatoplasty, sphincter pharyngoplasty, pharyngeal flap, combos -Dental appliances

46 Adenoidectomy- but why?Prepares surgery site- MUSC paper Irregularities in the adenoids Bulky adenoids If sleep apnea, tonsils may go too

47 Irregular adenoids

48 Palatoplasty Conversion from a straight-line repair Submucous cleftCreate bulk

50 Sphincter pharyngoplastyMUSC main choice This is a dynamic surgery that addresses lateral leaking Leaves central hole for breathing Should be surgical choice for 22q11 Still allows for a reduced overall diameter re: A-P closure

51 Sphincter Pharyngoplasty

52 Pharyngeal Flap Band of tissue that extends posteriory into phayrnxNot dynamic Will not address lateral leaks Arguably higher chance for sleep apnea My experience

54 Dental appliances Palatal lift Obturator

55 Therapy vs Surgery? Speech therapy can not correct a true VPISpeech therapy is recommended to acquire phonemes or eliminate erred speech (glottal stopping) Speech therapy is often recommended after surgery to facilitate oral pressure vs. nasal pressure now that mechanism is functioning properly Side note: when not to refer

56 Clinician VPI bedside Medical hx, including therapy historyPhrase list- remember to leave nasals out! Nasal mirror Consistency is key

57 VPI bedside- what to do if concernedThe importance of the team approach

58 M.A Hx: Pt saw me at age 3 for lateral “lisp.” Excellent language. Missing depressor angularis muscle on R side. Only noticeable when smiling. R sided fluid and inconsistently failed hearing screens on R side. Therapy for ~3-6 months, then d/c. Returned 3 years later with complaints that speech problems returned.

59 M.A. cont’d- perceptual evalEvaluation revealed mild lateral production of affricates and nasal air emissions inconsistently throughout speech most noticeable with affricates. What changed?- pt surgery

60 Case Study- M.A Results: Oral + /a/ syllables  Norms  S.D.  Score (mean)  Standard Deviation from Mean  pa, pa, pa…  6  3  57  46-66  ta, ta, ta…   7  4  49  42-57  ka, ka, ka…  7  4  49  40-55  sa, sa, sa…  7  5  40  33-49  sha, sha, sha…  7  4  47  44-54 

61 Case Study M.A Oral + /i/ syllables  Norms  S.D.  Score (mean)  Standard Deviation from Mean  pi, pi, pi…  17  7  85  79-88  ti, ti, ti…  17  7  82  73-88  ki, ki, ki…  18  8  84  80-91  si, si, si…  17  8  80  72-84  shi, shi, shi…  16  8  79  73-85 

62 Case Study M.A Nasal + /a/ syllables  Norms  S.D.  Score (mean)  Standard Deviation from Mean  ma, ma, ma…  53  13  71  50-97  na, na, na…  53  11  73  51-98     Nasal + /i/ syllables  Norms  S.D.  Score (mean)  Standard Deviation from Mean  mi, mi, mi…  72  13  89  80-98  ni, ni, ni…  74  11  87  77-98 

63 Cast Study- M.A Prolonged Sounds  Norms  S.D.  Score (mean)  Standard Deviation from Mean  Prolonged /a/  6  3  47  43-52  Prolonged /i/  19  9  77  73-81  Prolonged /s/  0  0  84  74-89  Prolonged /m/  93  3  97  87-97 

64 Case Study M.A Oral Passages  Norms  S.D.  Score (mean)  Standard Deviation from Mean  Bilabial Plosives  11  5  62  27-97  Lingual-Alveolar Plosives  11  5  62  31-97  Velar Plosives  13  6  59  31-96  Sibilant Fricatives  12  5  72  38-85     Nasal Passage  Norm  S.D.  Score (mean)  Standard Deviation from Mean  Nasals  54  9  76  48-98 

67 M.A Cont’d: Recs Speech therapy to correct articulation and to see if she was teachable Return to VPI clinic in 9 mos Follow up: Family came back ~3 years later, same results. Parents opted out of surgery.

68 Case Study- C.T Cleft lip and palate, repaired at Nationwide Children's in Ohio. Lip repair at 7 mos. Palate repaired around 14 months. Born term.  Unspecified heart problem per mom report. He has seen genetics, however, a diagnosis was not specified. He has sleep apnea, does not wear a mask. Mom wants to get rechecked. Mom states that he has "extra space in his brain", but could not name a specific cranial/neuro deficit. No nasal regurgitation when eating

69 Case Study- C.T

70 Case Study-C.T

71 Case Study- C.T

72 Case Study- T.C Perceptual What did we find?

73 Standard Deviation from Mean Case Study T.C Oral + /a/ syllables  Norms  S.D.  Score (mean)  Standard Deviation from Mean  pa, pa, pa…  6  3  8 1-23 ta, ta, ta…   7  4  13 6-39 ka, ka, ka…  6-10 sa, sa, sa…  5  18 6-31 sha, sha, sha…  15 5-32

74 Standard Deviation from Mean Case Study- T.C Oral + /i/ syllables  Norms  S.D.  Score (mean)  Standard Deviation from Mean  pi, pi, pi…  17  7  20 3-54 ti, ti, ti…  2-39 ki, ki, ki…  18  8  22 12-88 si, si, si…  45 16-74 shi, shi, shi…  16  33 21-66

75 Standard Deviation from Mean Standard Deviation from Mean Case Study- C.T Nasal + /a/ syllables  Norms  S.D.  Score (mean)  Standard Deviation from Mean  ma, ma, ma…  53  13  77 44-95 na, na, na…  11  49 29-92    Nasal + /i/ syllables  Norms  S.D.  Score (mean)  Standard Deviation from Mean  mi, mi, mi…  72  13  73 61-92 ni, ni, ni…  74  11  76 51-93

76 Standard Deviation from Mean Case Study- C.T Prolonged Sounds  Norms  S.D.  Score (mean)  Standard Deviation from Mean  Prolonged /a/  6  3  15 7-24 Prolonged /i/  19  9  77 47-98 Prolonged /s/  0  100-0 Prolonged /m/  93  92 90-95

77 Case Study-T.C 16 4-65 31 8-92 18 7-67 37 11-74 55 21-94 Oral Passages Norms  S.D.  Score (mean)  Standard Deviation from Mean  Bilabial Plosives  11  5  16 4-65 Lingual-Alveolar Plosives  31 8-92 Velar Plosives  13  6  18 7-67 Sibilant Fricatives  12  37 11-74    Nasal Passage  Norm  S.D.  Score (mean)  Standard Deviation from Mean  Nasals  54  9  55 21-94

80 Case Study- C.T What did we recommend? Why? Trial of S.TReturn in 6 months Differential: Why? Numbers, perceptual

81 Case Study- A.M She has a hearing loss (severe on LEFT side and RIGHT side is moderate. Hearing loss is progressive.  Diagnosed around age 2. Normal pregnancy and birth. She has sleep apnea and had her adenoids removed 1.5 years ago. Mom states hypernasality became worse after this.

82 Case Study- A.M

83 Case Study- A.M

84 Case Study- A.M -Perceptual- What did we find?

85 Case Study- A.M Oral + /a/ syllables   Norms   S.D.   Score (mean)   Standard Deviation from Mean   pa, pa, pa…   6   3   39  3-91  ta, ta, ta…    7   4   32  3-94  ka, ka, ka…   7   4   35  4-90  sa, sa, sa…   7   5   42  7-93  sha, sha, sha…   7   4   33  5-89 

86 Case Study- A.M. Oral + /i/ syllables   Norms   S.D.   Score (mean)   Standard Deviation from Mean   pi, pi, pi…   17   7   67  49-96  ti, ti, ti…   17   7   61  59-95  ki, ki, ki…   18   8   77  63-95  si, si, si…   17   8   56  31-89  shi, shi, shi…   16   8   54  39-78    

87 Case Study- A.M Nasal + /a/ syllables   Norms   S.D.   Score (mean)   Standard Deviation from Mean   ma, ma, ma…   53   13   52  30-96  na, na, na…   53   11   47  22-96     Nasal + /i/ syllables   Norms   S.D.   Score (mean)   Standard Deviation from Mean   mi, mi, mi…   72   13   67  42-96  ni, ni, ni…   74   11   78  67-97 

88 Case Study- A.M Nasal + /a/ syllables   Norms   S.D.   Score (mean)   Standard Deviation from Mean   ma, ma, ma…   53   13   52  30-96  na, na, na…   53   11   47  22-96  Nasal + /i/ syllables   Norms   S.D.   Score (mean)   Standard Deviation from Mean   mi, mi, mi…   72   13   67  42-96  ni, ni, ni…   74   11   78  67-97 

89 Case Study –A.M Prolonged Sounds   Norms   S.D.   Score (mean)   Standard Deviation from Mean   Prolonged /a/   6   3   27  22-32  Prolonged /i/   19   9   64  58-72  Prolonged /s/   0   0   0  100-0  Prolonged /m/   93   3   94  89-95    

90 Case Study –A.M Oral Passages   Norms   S.D.   Score (mean)   Standard Deviation from Mean   Bilabial Plosives   11   5   57  23-96  Lingual-Alveolar Plosives  11   5   56  14-96  Velar Plosives   13   6   57  32-95  Sibilant Fricatives   12   5   56  17-94   Nasal Passage   Norm   S.D.   Score (mean)   Standard Deviation from Mean   Nasals   54   9   76  40-98 

91 Case Study- A.M (prolonged /sh/)

93 References Kummer, A.W. (2001). Cleft palate and craniofacial anomalies: the effects on speech and resonance. San Dieago, CA: Singular. * Peterson-Falzone, S.J., Harding-Jones, M.A, & Karnell, M.P. (2001). Cleft palate speech. St. Louis, MO: Mosby. Biavati, M.J., Sie, K., Wiet, G.J., & Rocha-Worley, G. (2009, July 06). Velopharyngeal insufficiency. Retrieved from The impact of adenoid size on rate of revision sphincter pharyngoplasty. O'Connell BP1, Dobbie AM, Oyer SL, Montiel M, Hufnagle K, Patel KG, Discolo CM, Nguyen SA, White DR.

94 Melissa Montiel, MS, CCC-SLP