Nasometry, videofluoroscopy, and the speech pathologist's evaluation and treatment.

The speech-language pathologist (SLP) plays an important role in the assessment and management of children with velopharyngeal insufficiency (VPI). The SLP assesses speech sound production and oral nasal resonance and identifies the characteristics of nasal air emission to guide the clinical and surgical management of VPI. Clinical resonance evaluations typically include an oral motor exam, identification of nasal air emission, and analysis of the speech sound repertoire. Additional elements include perceptual assessment of intra-oral air pressure, the degree of hypernasality, and vocal loudness/quality. Clinical speech and resonance evaluations are typically the gold-standard evaluation method until a child reaches 3-4 years of age, when sufficient compliance levels and speech-language abilities allow for participation in instrumental testing. At that time, objective assessment measures are introduced, including nasometry, videofluoroscopy, and/or nasopharyngoscopy. Nasometry is a computer-based tool that quantifies nasal air escape and allows comparison of the score against normative data. Videofluoroscopy is a radiographic tool used to assess the shaping of the velum and closure of the velopharyngeal mechanism during speech production. Evaluation findings guide decision making regarding surgical candidacy and/or the therapeutic management of VPI. Surgery should always be pursued first when an anatomic deficit prevents velopharyngeal closure. Therapy should always be pursued in children who present with velopharyngeal mislearning and/or motor planning issues resulting in VPI. It is not uncommon for children to receive a combination of surgical intervention and speech resonance therapy during their VPI management course. Collaborative decision making between the otorhinolaryngologist and the SLP provides optimal patient care.