osha 2018 craniofacial assessment handouts · 2018-10-11 · hypernasality hyponasality nasal...
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10/10/18
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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
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