Velopharyngeal Insufficiency / Incompetence Clinic

Assessment Protocol in Our Clinic

The Velopharyngeal Insufficiency / Incompetence (VPI) Clinic at Cincinnati Children's Hospital Medical Center is a multidisciplinary clinic so that all necessary assessments can be done in one day. In addition, the clinic allows the specialists to work together to develop an appropriate and comprehensive treatment plan for the child.

Speech Assessment

The speech pathologist evaluates articulation (speech sound production), nasal air emission during speech, and resonance (nasality). The speech pathologist may also ask the child to repeat sounds and short sentences or answer simple questions as part of the evaluation.

Nasometric Assessment

Although the speech assessment can determine the type and severity of the speech and resonance disorder, it does not provide objective information. Therefore, the speech pathologist does an assessment using the Nasometer. The Nasometer is a computer-based instrument that measures the amount of sound in the mouth and in the nose during speech. The child wears a special headset that has specially designed microphones for this purpose. Once the headset is in place, the patient is asked to repeat sounds or simples sentences. The Nasometer gives the examiner an objective "nasalance score" that can be compared to normal speakers or to the patient’s previous tests.

Oral Examination

All team members will likely do an oral examination, which is quick and easy. The child is asked to open his mouth and say “aaah.” The examiners will want to see the soft palate (velum) and look for the presence of enlarged tonsils.

Nasopharyngoscopy

Although resonance disorders and velopharyngeal dysfunction can be identified from the speech evaluation, it is important to determine the cause, size, and location of the velopharyngeal opening. This information is needed so that the appropriate intervention can be determined.

The speech pathologist and otolaryngologist (ENT) work together to obtain information through nasopharyngoscopy (also called nasendoscopy). The nasopharyngoscopy procedure involves passing a very narrow scope (about the width of a piece of cooked spaghetti) through a nostril to the back of the nose. That way, it is possible to view the top of the velum. With the scope in place, the examiners can view the velum and the action of the entire velopharyngeal valve during speech.

Although nasopharyngoscopy is not a painful procedure, it can cause minor discomfort. To reduce the discomfort, a nose spray of a topical anesthetic and a decongestant are administered to the child before the procedure.

Nasopharyngoscopy requires a moderate degree of cooperation from the patient. This is due to the fact that the child must sit still and repeat sentences without crying. Our specialists can help to position the child and calm the child during the procedure. However, it is helpful if the parents prepare the child before the appointment. To help parents to prepare the child for the appointment, a Coloring Book is available in portable document format (.pdf), that explains the clinic visit is sent out prior to the appointment.

Genetics Assessment

The purpose of the genetics evaluation is to help determine the cause of the problem. This can assist the doctors in anticipating and treating medical and developmental issues that may be related to the diagnosis. The genetics evaluation can also help to determine the recurrence risk for the disorder so that the geneticist can counsel the family on the chance that the disorder will occur in other offspring.

The genetics evaluation includes an interview with the family to obtain information regarding the following:

Maternal illnesses during pregnancy and medications taken
The child's birth weight, length and head circumference
Specific birth defects, such as heart, eye or genital anomalies
Complications after birth, especially respiratory problems, seizures, or heart conditions
Developmental history
School performance
Family history for certain traits or anomalies
Treatment history

A standard physical examination of the child is done. In addition, there is an assessment of the following:

Growth parameters (weight, height or length, and head circumference)
The size and shape of the eyes, ears, mouth, nose, hands, fingers and numerous other structures
The unique features that may not be familial, but are specific to the child
The child's neurologic status, including muscle tone, level of function, and degree of social interaction.

Photographs are taken of the patient at each visit. It is also helpful if the parents bring in earlier photographs of the child, as well as photographs of other family members, to determine how certain traits are inherited.

After the history is reviewed and the examination is completed, additional tests may be ordered, such as a blood test (for analysis of chromosomes), X-rays, or an MRI scan of the brain. Referral to other physicians may also be necessary as part of a complete genetics assessment.

How do the team members interact with each other?

The team members of the VPI Clinic work together to assess the patient's speech, resonance, velopharyngeal function and genetic background. The team members try to determine the cause of the problem and the contributing factors during the assessment.

Immediately after the assessment, team members meet briefly to discuss their findings and impressions, and to determine recommendations for treatment. The findings and recommendations are communicated with the parents at that time. This interdisciplinary interaction and communication results in increased quality of care for the patient.