Velopharyngeal Dysfunction Clinic

Assessment Protocol

Speech Assessment

Speech pathologists conduct the first part of velopharyngeal dysfunction (VPD) assessments at Cincinnati Children's Hospital Medical Center.

By having the patient answer simple questions, repeat short sentences and talk spontaneously, the speech pathologist determines the type of resonance and whether there is also nasal air emission during speech. An articulation test is also done to determine whether there is difficulty in speech sound production.

Nasometric Assessment

Although a speech assessment can determine the type and severity of the resonance disorder, it does not provide objective information. Therefore, the speech pathologist does a nasometric assessment to essentially measure the amount of sound in the mouth and in the nose during speech.

The nasometer is a computer-based instrument that provides information regarding the amount of nasality found in a patient's speech. The nasometer has a headset that is designed to be worn by the patient during testing.

Once the headset is in place, the patient is asked to repeat sentences. Microphones on the headset pick up sound from the mouth and the nose during speech and give the examiner objective information regarding the patient's "nasality." The "nasalance score" is particularly helpful when determining progress achieved through surgery or speech therapy.

Nasopharyngoscopy

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

The speech pathologist and otolaryngologist work together to obtain this information through nasopharyngoscopy.

Nasopharyngoscopy has become the standard evaluation procedure for the evaluation of velopharyngeal function in patients with resonance disorders. This procedure involves passing a very narrow scope through a nostril to the back of the nose.

Although nasopharyngoscopy is not a painful procedure, it can cause minor discomfort.

To mitigate discomfort, a topical anesthetic and a decongestant are administered through the use of a nose spray. This is usually done by the nurse, but it can also be done by the parent or even by the child. With the scope in place, the examiners can view the velum and the action of the velopharyngeal valve during speech.

Nasopharyngoscopy requires a moderate degree of cooperation from the patient. This is due to the fact that in order to complete the study, the patient must sit still and repeat sentences, without crying, with the scope in place.

Genetics Assessment

The purpose of the genetics evaluation is to help make a diagnosis of 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 to look at 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, it may be necessary to order additional tests, 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?

Velopharyngeal Insufficiency team members work together to evaluate the patient's speech, resonance, velopharyngeal function and genetic background in order to determine the cause of the problem and the contributing factors.

After the assessment, team members meet to discuss the findings, impressions and recommendations for treatment. The final plan of care is determined by the team and communicated with the parents or caregivers. This interdisciplinary interaction and communication is certainly a benefit for the ultimate care of the patient.