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Overview
INSTRUMENTAL ASSESSMENT OF
VELOPHARYNGEAL DYSFUNCTION:
MULTI-VIEW VIDEOFLUOROSCOPY
VS. NASOPHARYNGOSCOPY
Mary K Berger M.S.CCC
University of Michigan Health Systems
Ann Arbor, MI
• Define and delineate velopharyngeal
dysfunction.
• Clinical examination
• Instrumental options
– Cephlagrams
– Nasopharyngoscopy
– Multiview videofluoroscopy
– Case presentations
What is hypernasal speech?
Hypernasality
• Definition: occurs when abnormal coupling of
oral and nasal cavities during speechespecially with vowel productions.
Due to structural,
neurogenic and/or
behavioral issues.
• Zoo Passage: Look at this book with us. It’s
a story about a zoo. That is where bears
go. Today it’s very cold out of doors, but
we see a cloud overhead that’s a pretty
white fluffy shape. We hear that straw
covers the floor of cages to keep the chill
away, yet a deer walks through the trees
with her head high. They feed seeds to
birds so they are able to fly.
Velopharyngeal Dysfunction
• Velopharyngeal Dysfunction
– implies faulty velopharyngeal closure
– the term encompasses the MANY causes or
contributors to impaired velopharyngeal function
– Many terms used synonymously
• Velopharyngeal insufficiency
• Velopharyngeal incompetence
• Velopharyngeal inadequacy
– But…the terminology should differentiate
the causes of VPD!
Velopharyngeal Incompetence
– Reduced movement of
soft palate
– Physiological cause
– Poor muscle function
– Pharyngeal hypotonia
– Velar paralysis or
paresis
– Dysarthria
– Apraxia
May require surgery or
therapy.
Velopharyngeal Insufficiency
– Palate too short
– Structural problem
– Not enough tissue at
time of initial cleft repair
– Submucous cleft (SMC)
– Deep pharynx due to
cranial base anomalies
– Following
adenoidectomy
Needs surgery to correct.
Phoneme specific
velopharyngeal incompetence
• Velopharyngeal mislearning
– Hypernasality or nasal air emission due to
faulty articulation
– Occurs due to pharyngeal or nasal articulation
of certain sounds
– Causes phoneme-specific nasal emission
(usually sibilant sounds).
Never surgery-always speech tx
Scope of the
Problem?
• 5-25% of patients with a
cleft palate despite optimal
care will have persisting
velopharyngeal dysfunction.
• Where do we begin to
assess this communication
problem?
*Speech Perceptual Analysis =
Gold standard*
(trained, experienced speech
language pathologist)
Manifestations of VPD
• Secondary Manifestations
–Nasal grimace
–Hoarseness
–Vocal cord nodules
–Short utterance length
–Hypophonia
Manifestations of VPD
• Primary Manifestations
– Inappropriate air flow
– Nasal rustle/ turbulence
– Hypernasal resonance
– Compensatory misarticulations
– Reduced speech intelligibility
– Nasal regurgitation
So you suspect VPD - What next?
• Joint appointment with speech language
pathologist and surgeon
– Perceptual speech examination by SLP
– Indirect assessments (Nasometry, pressure flow
studies)
– Direct assessment (nasopharyngoscopy-NE,
multiview videofluoroscopy-MVF)
Timing of Speech Evaluations- when
should this occur?
• Adequate vocabulary/language
to provide a good speech
sample
• Behavioral/cognitive maturity to
cooperate with the examination
• Behavioral capability to tolerate
instrumental evaluation if
deemed necessary
= Late 3 to 4 years of age…
Clinical Exam
• Cul de sac testing:
Produce the oral
words/sentences with
the nose open then with
the nose closed. If
normal resonance, will
be identical productions
(Bzoch, 1979).
• Nasal mirror testing for
nasal emission-often
accompanies
hypernasality.
Timing of Speech Evaluations
• Deterioration in velopharyngeal function
may occur with:
– Palatal expansion
– Tonsil/ adenoidal involution
– Tonsillectomy/ adenoidectomy
– Maxillary advancement surgery
Speech perceptual evaluation should occur
annually as part of a comprehensive cleft
evaluation
Clinical Exam
• Tongue anchor technique: puff cheeks around
protruded tongue (Dalston et al, 1990)
• See-Scape
• Listening tube/stethoscope
• Repeat standardized words, sentences, serial
counting and spontaneous speech sampling.
• Assess for presence of compensatory
misarticulations
Evaluation of Velopharyngeal Port
Instrumental Evaluation
• Purpose: determine presence, extent, location
of abnormalities that lead to VPD
• Indirect assessment (Nasometry,
Aerodynamics): confirm presence and
quantify hypernasality
• Direct assessment: anatomic deficiencies,
abnormalities in anatomy/physiology
• Refining our diagnosis.......need direct imaging
to establish the plan before sending a patient
out for therapy vs. surgery?
Instrumental Options
• Nasometry
• Aerodynamic (pressure flow studies)
• Nasopharyngoscopy (NE)
(nasendoscopy/videonasendoscopy)
• Multiview Videofluoroscopy (MF) (multiplaner fluoroscopy)
• Lateral Cephalometric radiographs
• Cineradiography/Cinefluoroscopy
9 fMRI- not cost effective
9 Spectrography
9 Accelerometry
9 research only
Scope of Practice –
Speech Language Pathology
• Scope of Practice in Speech-Language Pathology
• Document Type: Scope of Practice Year: 2007
Source: ASHA Practice Policy
DOI: 10.1044/policy.SP2007-00283
http://www.asha.org/docs/html/SP2007-00283.html 126 KB
• “using instrumentation (e.g., videofluoroscopy,
electromyography, nasendoscopy, stroboscopy,
endoscopy, nasometry, computer technology) to
observe, collect data, and measure parameters of
communication and swallowing or other upper
aerodigestive functions”
Nasometry
AERODYNAMIC ASSESSMENT
• Measurement of nasal
acoustic energy
• Objective and
quantitative
• Score reported as
“nasalance” percentage
and is compared to
established norms and an
individual’s prior scores
• Indirect assessment
Direct Imaging Advantages
• Diagnose the cause of VPD-anatomy, physiology
• Target for appropriate therapy/surgery
• May assess for effectiveness of therapeutic
techniques
• Plan surgery as appropriate
• Tailor the surgery to patient’s anatomical needs
• Quantitative measures can also be used to judge
progress with subsequent therapy
Direct Imaging
• Goals:
– Image structures of palate and
velopharyngeal port
– Image in motion
(swallowing, speaking)
– Record of study
Direct Imaging Options
Lateral
Cephalogram
• Lateral Cephalometric radiographs-still images
• Cineradiography/Cinefluoroscopy (sharper
images but 10x the radiation exposure-no
longer used)
• Nasopharyngoscopy (NE)
(nasendoscopy/videonasendoscopy)
• Multiview Videofluoroscopy (MVF)
Lateral Cephalogram
Disadvantages:
• Not assessing connected speech
• May produce other sound (/s/ error)
• Unable to assess closure of velopharyngeal
(VP) port as 2-D
• Difficult to see small gaps without contrast
material
Frontal and Base
Cephalogram
• Still images only
• View of rest breathing
then during phonation
(sustained /s/)
• Length and configuration
of velum
• Shape and depth of
nasopharynx
• Maximal velar height
and contact
• Approximation to
posterior pharyngeal
wall with static sound
• Can take measurements
• Frontal view must
have contrast to see
gaps due to anatomy
of frontal bones and
cervical vertebrae
• Base view shows
several levels in vocal
tract (“cylinder”)
including base of
tongue, larynx and
velum
Nasopharyngoscopy
Flexible fiberoptic
endoscope inserted
through the naris(es)
(pediatric scope 2.1-2.4
mm)
• Superior view of VP port
at rest and during speech
• Permits visualization and
evaluation of VP
structures (velum,
posterior pharyngeal
wall, lateral pharyngeal
walls, …).
Nasopharyngoscopy-Advantages
– Engage in normal speech
– Unlimited length of study
– Consistency of
productions/incomplete closure
– No radiation
– More sensitive for small gaps, SMC,
occult cleft, levator dehiscence
– Better evaluation of palatal and
pharyngeal anatomy
– Irregularities of the adenoid
– Surgeon visualize the anatomy
– Access to visual image for
biofeedback thearpy
– Image record
– Post-operative assessment
– More cost effective than
radiographic study
Velopharyngeal Closure Patterns
Coronal closure
Circular closure
Circular closure with
anterior movement
of post pharyngeal
wall
Saggital closure
Nasopharyngoscopy-Disadvantages
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Cooperation
Topical anesthetic (allergic response)
Vasovagal risk
Highly skilled examiners/interpreters
Antibiotic prophy needed if cardiac
precautions
Placement consistency
Optical distortion of view
Secretions interfere with image
Nasal anatomy issues with passing
scope
Reduced view of lateral pharyngeal
walls
Length/thickness of velum unknown
Relationship of Passavant’s ridge to the
palate
Multiview
Videofluoroscopy
(MVF)
Multiview Videofluoroscopy (MVF)
• Radiologic study to assess velopharyngeal
movements.
• Uses lateral, frontal and base or Towne’s views
• Originally published by Skolnick in 1969 and
1970
Multiview Videofluoroscopy (MVF)Advantages
Multiview Videofluoroscopy (MVF)
Three views taken:
A. Lateral
B. frontal (anterior to
posterior)
C. Base or Towne’s
view
Skolnick ML and Cohn ER,
Videofluoroscopic Studies
of Speech in Patients with
Cleft Palate, SpringerVerlag, New York, (1989).
THE text for understanding
and learning the technique
of MFV.
Still in print with prices from
$100 -$200 online.
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Direct visualization
Gives 3-dimensional view of velopharyngeal port
Dynamic study
Can take actual measurements
Assists with planning treatment/ surgery
May work with younger children
No insertion of tube or anesthetic (use barium)
Reduced radiation exposure by 50-75% using pulsed
fluoroscopy (Hernandez and Goodsitt, ; Brown et al.
2000)
Multiview Videofluoroscopy (MVF)Disadvantages
ƒ Invasive with radiation exposure-including to eyes and thyroid
ƒ 3 consecutive views needed so increase radiation . Limits speech
sampling options.
ƒ Assumes vp mechanism performs consistently
ƒ Requires maximal cooperation; must sit motionless for best views
ƒ Requires injection of barium into the nares
ƒ Mucus may interfere with barium coating
ƒ Base view (sphinx position) difficult
ƒ Highly skilled examiner(s)
ƒ Only available in hospitals
ƒ More expensive
Comparison MVF and NE
– Golding-Kushner et al (1990) work group
recommend methodology and reporting
standards.
– Henningsson and Isberg (1991): NE failed to
demonstrate amount of LPW movement
compared to MVF; adenoid interfered with NE
view, positioning the endoscope lower is critical.
– Pigott (2002): Review article. Take caution with
measurements from MVP and NE. Large range of
normal.
Comparison MVF and NE
– Croft, Shprintzen and Rakoff (1981): identified
similar closure patterns; studies assist with
surgical planning.
– Sinclair, Davies and Bracka (1982): MVF and NE
similarly defined VP isthmus; lat VF unreliable
estimate of closure, NE more reliable than base
view VF and s/p PPF.
– Stringer and Witzel (1989): Lateral view
inadequate for description of VP movements;
Towne’s view compared to NE view.
Comparison MVF and NE
• Lam et al. (2006): NE and MVP complimentary data
however NE shows stronger correlation with VPI gap
size and role of LPW at level of maximal velar
elevation .
• Lipira et al. (in press): NE and lateral view MVF
moderately correlated. LVF gave smaller gap
estimates. Facial grimace associated with larger gap
size. Velar movement angle and change in genu angle
anatomical correlates of closure function.
Incidence of Diagnostic Techniques
• Lauck et al (2006): ACPA members and Division 5
ASHA surveyed with 93 questionnaires completed
regarding how they evaluate speech.
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Intra-oral exam (90.2%)
Perceptual evaluation (93.5%)
Nasometry (44.6%)
Videofluoroscopy (44.6%)
Nasendoscopy (83.5%)
Aerodynamic measures (14.4%)
Multiview Videofluoroscopy
• Equipment needed:
– Radiologic equipment
– Seating system
– Microphone
– Recording system with audio
– Monitor
– Lead apron for gonad region
– Nectar thick colloidal barium sulfate in 5 or 10 cc
syringe
NASOENDOSCOPY VS.
VIDEOFLUOROSCOPY
Kummer (2007) surveyed 376 ACPA Craniofacial
Centers regarding diagnostic tools. 136
responses (43% return) with average 17 yrs
experience.
→ 93% used NE (always important)
→ 68% used MVF (sometimes important)
The more experience, the more both were
employed based on clinical question
Preparation for the Study
Prior to the scheduled appointment:
• Discuss procedure with parents at time of
clinic visit
• Send written description to parents (coloring
book or pictures for child)
• Check for allergies to contrast (barium)
• Child practices sniffing (smelling the flowers)
• R/s appointment if child is very congested
Day of MVF
MVF ProcedureBarium
instillation
• Be honest; tell child ahead of
time
• Show child around the room
(have him find the camera, the
mic, the TV)
• Parent generally attends
(important to put parent at ease
to help child)
• Stickers on the screen of camera
for frontal view visual focus
• Sit in chair (standing makes ↓
movement more challenging)
• Practice being a “talking statue”
• Taste barium (frosting)-clinician
and parent take taste and show
coated tongue
• Patient blows nose to clear
secretions if possible
• Head/neck in hyperextension
(sticker on ceiling)
• Inject barium into nares
(approx. 2 cc per naris) and cue
patient to sniff and swallow
• Use 5-10 cc syringe, dropper or
soft rubber catheter left in
naris to administer barium
• May need more barium
injected for other views if poor
coating noted.
MVF
Lateral view only without
Procedure barium at rest, with
sustained /s/, oral sentences
from protocol, nasal
sentences.
Begin study without barium
just in case lose cooperation
after barium administration
so obtain some information;
easier to see PPF without Ba.
No other views appropriate
without barium due
obstruction of anatomy.
MVF Procedure- Barium instillation
If concerned about
communicating
oronasal fistula,
inspect oral cavity and
look for barium
emerging after
injecting
MVF Procedure
• Lateral view, Frontal view (Anterior-posterior
view) and Base or Towne’s view depending on
adenoid size
• In each view view: swallow, sustained /s/ and
/sh/, repetitive C-V syllables, words, sentences,
serial counting.
• Turn off x-ray while clinician delivers stimulus
• Cue patient to watch clinician in lateral and base
views, at sticker on the screen in A-P view, at
their belly button in Towne’s view.
Lateral View - MVF
• Remember flexion narrows vp gap; hyperextension
increases gap and appearance of Passavant’s ridge.
• Palatine and lingual tonsils impacting vp port closure and
tongue movement
• Compensatory misarticulations
• Airway status (?OSA); base if tongue position
• Barium bubbling through port c/w small gap (ABNQ)-look
for 2 separate lines (central vs. lateral gap unclear); wide
vp gap, no barium bubbling noted.
• Palate depression with nasal productions
• Inconsistent closure with vowels particularly in mixed
nasal/non-nasal context
• With orals, velum remaining elevated throughout
utterance
Lateral View MVF
• Length of velum
• Thickness of velum (↑ post-repair;
↓ tissue insufficiency)
• Distance between PPW and velum at
rest and with maximum phonatory
effort
• “Velar stretch” or elongation of the
palate with non-nasal productions
• Location and height of velar
eminence
• Size of adenoid and relation to velar
elevation
• Passavant’s ridge (muscle fibers of
palatopharyngeus vs. superior
constrictor muscle or both)
• Anterior movement of PPW
Frontal View- MVF
• Ensure adequate Ba coating; tilt
head slightly up if view obscured
• Head centered (not rotated) by
lining up mandibular vertical
rami and condyles
• Symmetry and mesial movement
of LPWs
• Level of maximum LPW
movement in relation to the
velum or the PPF
• Quantify LPW movement on
each side (4 equal spaces:
1=25%, 2=50%, 3=75%, 4=100%
or to midline)
• With swallow, LPW movement
more in oropharynx (lower)
Base View - MVF
Base View - MVF
• Similar to NE view (enface
view of vp port)- vp port is
an oval structure
• Head perpendicular to the
direction of the x-ray beam
(sphinx position-prone on
table up on elbows)
• Enables simultaneous view
of soft palate, LPW and
PPW creating “sphincter
like” narrowing
• Effective to assess posterior
pharyngeal flap (PPF),
dynamic sphincter
pharyngoplasty (DSP), SMC
• Confuse movement of
structures lower in
pharynx (base of
tongue, larynx) for
palatal movement
• Unable to see port if
hypertrophied
adenoid
• Not feasible if patient
too large or unable to
adequately
hyperextend neck
Towne’s view- MVF
Oblique View- MVF
(Stringer and Witzel, 1986, 1989)
• Enface view with large
adenoid
• Patient sits upright with
chin hyperflexed looking
down (“talk to your belly
button”) with beam
through back of head,
perpendicular to beam
• May provide better view
than base view
• Another option if can’t achieve base position and
large adenoid-limited productions
• Begin in lateral view then rotate head/body
toward frontal position then back to lateral on
other side, moving approximately 45 degrees
• Takes 10-15 sec while continually repeating oral
CV syllable (“pa pa pa pa”)
• Asymmetries seen as view anterior half of palate
• SMC appreciated by “V” at knee of velum
Measuring
Techniques
with MVF
• Place reference on screen
(penny, paper clip)
• Quantifying LPW
movement, velar excursion
on linear scale
• Lam et al. (2006) and
Karnell et al. (1983)
attempted to quantifydifficult
• Complete tracings for
measurement accuracy
• Still often subjective
MVF Case Presentations
Bibliography
Bibliography
• Brown PH, Thomas RD, Silberberg PJ, Johnson LM: Optimization of a
fluoroscope to reduce radiation exposure in pediatric imaging. Pediatric
Radiology 30: 229, 2000.
• Bzoch KR (Ed.): Communicative Disorders Related to Cleft Lip and Palate,
2nd Ed., Little, Brown, Boston, 1979.
• Croft CB, Shprintzen RJ and Rakoff SJ: Patterns of velopharyngeal valving in
normal and cleft palate subjects: a multi-view videofluoroscopic and
nasendoscopic study. Laryngoscope 91: 265, 1981.
• Dalston RM, Warren DW and Dalston ET: The modified tongue-anchor
technique as a screening test for velopharyngeal inadequacy: a
reassessment. CPJ 55: 510, 1990.
• Golding-Kushner KJ et al: Standardization for the reporting of
nasopharyngoscopy and multiview videofluoroscopy: a report from an
International Working Group. CPJ 27: 337, 1990.
• Henningsson G and Isberg A: Comparison between multiview
videofluoroscopy and nasendoscopy of velopharyngeal movements. CPJ
28: 413, 1991.
• Hernandez RJ and Goodsitt MM: Reduction of radiation dose in pediatric
patients using pulsed fluoroscopy. Am J of Roentgenology, 167, 1247
(1996).
• Kummer, A. (2008). Cleft Palate and Craniofacial Anomalies – Effects on
Speech and Resonance. (2nd Ed.). Clifton Park, NM: Delmar Cengage
Learning.
• Peterson-Falzone, SJ, Hardin-Jones, MA, Karnell, MP. (2010). Cleft Palate
Speech (Fourth ed.). St. Louis, Missouri: Mosby Elsevier.
• Karnell MP et al: Reliability of the nasopharyngeal fiberscope (NPF) for
assessing velopharyngeal function: analysis by judgment. CPJ 20: 199,
1983.
• Lam DJ, Starr JR, Perkins JA, Lewis CW, Eblen LE, Dunlap J, Sie KC: A
comparison of nasendoscopy and multiview videofluoroscopy in assessing
velopharyngeal insufficiency. Otolaryngology Head and Neck Surgery 134:
394, 2006.
• Lauck L et al: Speech outcomes following surgical management of
velopharyngeal dysfunction: a survey of craniofacial teams, American Cleft
Palate Craniofacial Association Annual Meeting, 2006.
• Lipira A et al: Videofluoroscopic and nasendoscopic correlates of speech in
velopharyngeal dysfunction. CPJ (in press) CPJ (2011)
Bibliography
• Pigott RW: An analysis of the strengths and weaknesses of endoscopic and
radiological investigations of velopharyngeal incompetence based on a 20
year experience of simultaneous recording. JPRAS 55: 32, 2002.
• Sinclair SW, Davies DM, Bracka A: Comparative reliability of nasal
pharyngoscopy and videofluorography in the assessment of
velopharyngeal incompetence. Br J Plast Surg 35:113, 1982.
• Skolnick ML: Video velopharyngography in patients with nasal speech with
emphasis on lateral pharyngeal motion in velopharyngeal closure.
Radiology 93: 747, 1969.
• Skolnick ML: Videofluoroscopic examination of the velo-pharyngeal portal
during phonation in lateral and base projections-A new technique for
studying the mechanics of closure. Cleft Palate Journal 7: 803, 1970.
• Skolnick ML and Cohn ER, Videofluoroscopic Studies of Speech in Patients
with Cleft Palate, Springer-Verlag, New York, (1989).
• Stringer DA and Witzel, MA: Comparison of multi-view videofluoroscopy
and nasopharyngoscopy in the assessment of velopharyngeal insufficiency.
CPJ 26: 88, 1989.
C.S. Mott Children’s
Hospital- Opening 2011
Thank you.
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