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Foundations of Assessment Techniques in Children with Repaired Cleft Palate /

Craniofacial Conditions

Kerry Mandulak: Pacific UniversityKameron Beaulieu, Janet Brockman, Hannah Sanford-Keller: IDD/OHSU

OSHA Annual Conference: October 13, 2018“Strength in Collaboration”

Please text “kerrymandula887” to “37607” to join our session!

DisclosuresMandulak

➔ Financial: Salary at Pacific to teach graduate course in Cleft / Craniofacial➔ Non-financial: Board of Directors for Smile Oregon, SIG 5 (Craniofacial &

Velopharyngeal Disorders

Beaulieu

➔ Financial: Salary from IDD/OHSU to work in Cleft Palate/Craniofacial Disorders Clinic

➔ Non-financial: None

DisclosuresBrockman

➔ Financial: Salary from IDD/OHSU to work in Cleft Palate/Craniofacial Disorders Clinic

➔ Non-financial: None

Sanford-Keller

➔ Financial: Salary from IDD/OHSU to work in Cleft Palate/Craniofacial Disorders Clinic

➔ Non-financial: None

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Learning ObjectivesIdentify speech characteristics (both obligatory and learned) that may be due to structural versus functional issues (or both);

Identify specific treatment strategies that would be recommended after the assessment process, based on the findings;

Discuss appropriate referral options based on speech production assessment results.

TEAM CARE: The gold standard

Journal of Lancaster General Hospital, 2009

Interprofessional Practice : History of Cleft / Craniofacial Care

American Journal of Public Health, 1960

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Cleft / Craniofacial Team

INTERDISCIPLINARY … (not MULTIDISCIPLINARY)

References:https://acpa-cpf.org/team-care/standardscat/parameters-of-care/

Austin, et al. (2010) - Comparing interdisciplinary care teams with individual providers

Cleft / Craniofacial Team (ACPA Standards of Approval for Team Care, https://acpa-cpf.org/team-care/standardscat/standards-of-approval-for-team-care/)

Minimum Core Members:

➔ Speech - Language Pathology, Surgery, Orthodontic Specialties

Includes a Patient Care Coordinator

Includes access to the following specialties:

➔ Psychology, social work, audiology, genetics, general and pediatric dentistry, otolaryngology, pediatrics / primary care

➔ Craniofacial teams require a surgeon trained in transcranial cranio-maxillofacial surgery and access to psychologist who can complete neuropsychological testing

Cleft Care Timeline● 0-3 months: Lip taping/NAM, feeding support● 3 months: Primary lip and nose surgery● 12 months: Palate and/or ear tubes● 12 months- 4 years+: Speech intervention, speech evaluations every 6

months for intervention guidance, dental care, hearing● 4 years +: Secondary surgery for velopharyngeal dysfunction● 7 years +: Orthodontics● 8 years- 10 years: Bone graft to gum line● 14 years- 16 years: Nose surgery, orthodontics● 16 years- 21 years: Jaw surgery

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CFD Team Speech Pathology Timeline

● Feeding evaluation and treatment as needed● 3 months before primary palate repair● 3 months after primary palate repair● Every 6 months until 5 years of age to monitor treatment

progress, language/articulation, nasal resonance balance● Nasopharyngoscopy (as needed) to support surgical

interventions● Every 6 to 12 months until 18 years of age to monitor voice,

articulation, and nasal resonance balance

Family / Child / SLP / Team SLP : ALSO a TEAM

We all need to work … TOGETHER

All “experts!”

Child & Family

School / Community

SLP

Team SLP

Inaccurate Description / Diagnosis

Incorrect / Less Effective Treatment Plan

No / LittleImprovement

Lack ofConfidence

Fitzsimons, 2012

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Assessment: ResponsibilityBurden of Care // Surgical Decision Making

➔ Outcome of SLP evaluation needed for surgical decisions➔ Have to have trained ears and trained eyes➔ High volume of patients leads to skill development➔ Appropriate referrals lead to appropriate treatment

Ears + Imaging + Critical Thinking + All of that Phonetics / Speech Science / Graduate Training … together!

Let’s Talk About Terminology

One too many termsHypernasalityHyponasalityMixed ResonanceCul de sac resonanceAudible Nasal EmissionNasal TurbulenceActive Nasal FricativesActive Nasal Fricatives with Turbulence

Passive Nasal FricativesPassive Nasal Fricatives with TurbulenceInaudible Nasal EmissionPhoneme Specific Nasal EmissionWeak ArticulationNasal GrimaceNasal Realisation

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Velopharyngeal Dysfunction (VPD)

(Peterson-Falzone, et al: A Clinician’s Guide to Treating Cleft Palate Speech. Mosby Elsevier, 2006)

“Nasal Sounding Speech”

Resonance /Nasalisation

Abnormal Nasal Airflow

HyponasalityHypernasality Nasal Emission

Nasal TurbulenceCul de SacResonance

Potato-in-the-mouth Resonance

Inaudible Nasal Emission

Nasal Grimace

Articulation /Phonology

Articulation /Phonology

Organization of Terms

Equipment and Operator

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Equipment and OperatorEQUIPMENT: Consistent hypernasality, consistent nasal air emission, weakened oral pressure consonants and/or “structural” errors (dental hazards)

➔ Obligatory or unavoidable errors ➔ Secondary surgery / Orthodontic / Orthognathic management

OPERATOR: Compensatory articulation errors

➔ Learned errors ➔ Specific to children with repaired cleft palate➔ Require speech therapy / behavioral intervention

“Perceptual Speech Evaluation”Intra-Oral Exam // Oral Mechanism Examination

Speech Production : Specific to cleft / craniofacial (Equipment vs Operator)

➔ A: Articulation➔ R: Resonance➔ A: Airflow

Speech - Language Evaluation : General

➔ Speech, language, voice, fluency, pragmatics, feeding / swallowing

Decision making for treatment // Referrals

Examining Oral Structures : The Intra-Oral ExamFox, L. (2018). Examining the orofacial structures in patients with craniofacial differences. Perspectives of the ASHA Special Interest Groups, August 2018, Vol. 3 (SIG 5), 24-35. doi:10.1044/persp3.SIG5.24 https://perspectives.pubs.asha.org/article.aspx?articleid=2697777#

➔ Structure // Function // Movement // Symmetry

➔ Hard palate (fistulae) = effects on airflow / articulation

➔ Soft Palate (bifid uvula) = effects on resonance

➔ Occlusion (missing / malrotated teeth) = acoustics of fricatives

➔ Craniofacial differences (facial, anterior oral structures, posterior oral structures)

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A R A : Articulation, Resonance, AirflowThe American English Sentence Sample (CAPS-A-AM)

Mom ‘n Amy are home (/m/)Puppy will pull a rope (/p/)Buy baby a bib (/b/)A fly fell off a leaf (/f/)I love every view (/v/)Thirty-two teeth (”th”)The other feather (voiced “th”)Anna knew no one (/n/)Your turtle ate a hat (/t/)Do it today for Dad (/d/)Laura will yell (/l/)

Sissy saw Sally race (/s/)Zoey has roses (/z/)She washed a dish (“sh’)Watch a choo-choo (“ch”)George saw Gigi (“dge”)We are hanging on (“ng”)A cookie or a cake (/k/)Give Aggie a hug (/g/)Hurry ahead Harry (/h/)I spy a starry sky (/sp/ /st/ /sk/)Ray will arrive early (/r/)We were away (/w/)We ran a long mile (hyponasality)

Modifiedfrom:Trost-Cardamone J.(2013).AmericanEnglishSentenceSample(AESS),inCleftPalateSpeech,AComprehensive2-PartSet.AmericanSpeech,Language,HearingAssociation(ASHA).ProfessionalDevelopmentCourse,Part1.ASHAStore.www.asha.org/shop

Differential Diagnosis of Error TypeDevelopmental (non-cleft related)

Obligatory (Equipment)

Velopharyngeal Mislearning (VPM) (equipment + operator)

Maladaptive articulation

Phoneme-specific VPI

Motor Speech (Operator)

Velopharyngeal Mislearning // Compensatory Articulation

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Velopharyngeal Mislearning // Compensatory Articulation

Resonance DisordersHYPERNASALITY = Excessive nasal energy

To evaluate:Vowels & vocalic consonants“Pull the baby buggy”“Wash the dish”

Quick check:Sustain [i] [u] and intermittent pinch

naresSuggests hypernasality if resonance

shift present.

HYPONASALITY = Not enough nasal energy

To evaluate:Nasal consonants[m]-->[b]“Mommy made lemon jam”

Quick check:Hum “Happy Birthday” w/o

breathing through mouthSuspect inadequate nasal airflow if

unable.

Decision - Making Tree (adapted from / credit to Seattle Children’s Hospital)

Perceptual Evaluation

Hypernasality, NAE, “normal” articulation

Refer to Cleft / Cranio Team for

Evaluation

Hypernasality, NAE, compensatory

articulation

Refer to Cleft / Cranio team for

Evaluation

Initiate speech therapy to establish oral place of artic // appropriate valving for

PCs

Compensatory articulation, phoneme specific NAE, normal

resonance

Initiate speech therapy for articulation

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Mechanisms for ReferralFOUR cleft and/or craniofacial teams in Oregon (https://cleftline.org/find-a-team/)

➔ Doernbecher Children’s Hospital at OHSU

➔ https://www.ohsu.edu/xd/health/services/doernbecher/programs-services/cleft-palate-craniofacial.cfm

➔ Kaiser Permanente Northwest Cleft Palate Clinic

➔ https://healthy.kaiserpermanente.org/oregon-washington

➔ Randall Children’s Hospital at Legacy Emanuel

➔ https://www.ohsu.edu/xd/health/services/doernbecher/programs-services/cleft-palate-craniofacial.cfm

➔ Shriners Hospitals for Children in Portland

➔ https://www.shrinershospitalsforchildren.org/portland/cleftlippalate

Case Examples : Assessment Principles

Early Intervention

● 2 years, 1 month● Cleft diagnosis: Median incomplete cleft palate● Surgeries: Cleft palate repair with intact palate

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When to scope?

● Initiate intervention first● Monitor progress- scoping may not be warranted● Refer to CFD team if palatal dysfunction is suspected or if

questions remain

Dynamic Assessment / Stimulability / Txmt Goals

Dynamic Assessment / Stimulability / Txmt Goals

Have to try to see what they CAN do (in addition to documenting what’s difficult)

Creating treatment goals as you go (and checking for stimulability)

Come up with facilitating techniques to communicate to treating SLP

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Preschool

Scoping Contexts

● Oral productions of air-pressure sounds○ P, B, T, D, K, G

● NOT crying, vowel sounds, error patterns such as glottal replacement or pharyngeal fricatives

● Age/behavior○ Able to tolerate nasal spray and introduction of flexible endoscope into the nasal cavity

○ Able to sit without moving the head side to side

Hypernasality / Resonance

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Equipment versus operator?

● Therapy is not indicated as she has perfect articulation ● Scoping is indicated as she demonstrates consistent nasal air

emission and hypernasality● The rub: She had fluctuating hyper and hyponasality

RESOURCES

Textbooks

Online educational courses

ASHA products

Thank you so much for listening!

Mandulak@pacificu.edu – 503.352.1464Beauliek@ohsu.edu – 503.494.4024Brockman@ohsu.edu – 503.494.2741Sanfordh@ohsu.edu - 503.494. 2737