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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 • • • • • • • • • • • • 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. • • • • • • • • 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 Invasive with radiation exposure-including to eyes and thyroid 3 consecutive views needed so increase radiation . Limits speech sampling options. Assumes vp mechanism performs consistently Requires maximal cooperation; must sit motionless for best views Requires injection of barium into the nares Mucus may interfere with barium coating Base view (sphinx position) difficult Highly skilled examiner(s) Only available in hospitals 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. – – – – – – 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. [email protected]