Procedure for Nasopharyngoscopy
If you would like us to review information about the treatment of velopharyngeal insufficiency, it would be important for us to see the actual examinations performed (not the reports of the examinations) to share our opinions with the people who will be making the treatment decisions and providing treatment. Nasopharyngoscopy has become indispensible component of the assessment of velopharyngeal insufficiency. The procedure is also often applied to assess airway related problems and feeding problems (a procedure known as FEES for Fibertoptic Endoscopic Evaluation of Swallowing). The description below relates specifically to speech and velopharyngeal insufficiency. If you need information on other applications of nasopharyngoscopy, let us know and we will provide it to you.
The information derived from nasopharyngoscopy is extremely important in assisting clinicians in the process of determining if surgery for velopharyngeal insufficiency is needed in any individual case. It is extremely important that the procedure include specific elements, otherwise false positive or false negative results are possible.
ALL ENDOSCOPIC EXAMINATIONS MUST BE RECORDED USING A VIDEO RECORDING SYSTEM WITH SOUND. Examinations that are not recorded are useless because only one person can see the examination and the examination cannot be viewed with others in order to discuss the outcome. It is also possible to miss important components of the examination, and all examinations should be reviewed on multiple occasions. Most modern endoscopic equipment can be easily set up to record digital video so the examination can be saved and shared as a digital video file or burned to a DVD. In some places, video tape is still being used and this is better than nothing. VIDEO RECORDING WITH SOUND IS ESSENTIAL. VIDEO WITHOUT SOUND COMPROMISES INTERPRETATION OF THE STUDY.
Among our experts are clinicians who have performed and reviewed more than 10,000 fiberoptic nasopharyngoscopic examinations. Dr. Shprintzen was the first American to utilize and report on his experience using fiberoptic endoscopy to assess velopharyngeal function in the early 1970s. Since that time, he has published many papers, chapters, and texts on the procedure. This information sheet reflects the combined experience of our staff and the 38 years of experience of Dr. Shprintzen.
Age at Examination
Successful nasopharyngoscopy is highly dependent on sufficient compliance with the procedure. This means that the child must be cooperative enough so that a good visualization of the entire pharynx can be obtained, AND an adequate speech sample must be repeated during the examination. It is our preference to defer nasopharyngoscopy to assess velopharyngeal function until 4 years of age because it is the very rare child who will cooperate with the procedure before that time. In the case of velo-cardio-facial syndrome specifically, many children with the syndrome have limited speech production prior to that age and this will limit the usefulness of the procedure. Therefore, we typically defer surgical treatment until an adequate examination of the velopharyngeal mechanism can be obtained (usually around 4 to 5 years of age). The velopharyngeal mechanism cannot be assessed during crying or screaming. This is not normal speech production and decisions about treatment should not be made if normal speech was not obtained. The velopharyngeal mechanism does not function normally during crying or screaming and false positives or false negatives are possible, if not common. It is possible to obtain a good examination if the child is crying initially but calms down during the examination when it is determined that the examination is not painful.
It is important to have a comprehensive speech sample prepared that the person being examined will repeat. Because there is no time limit on nasopharyngoscopy, additional speech can be obtained, but there must be a minimum sample that contains the following elements:
1.All consonant speech sounds found in the language.
2.Samples that do not contain normally nasalized consonants (the m, n, and ng sounds).
3.Sustained voiceless fricative (including sibilant) sounds…specifically a sustained sssss and fffff. A sustained sh is often useful, as well.
4.Transitions from normally non-nasal to normally nasal consonants.
A recommended sample, one we have been using for many years, is the following:
ssssssss (sustained s)
Suzy sees Sally
ffffffff (sustained f)
Stop the bus
Catch a fish
1-2-3-4-5-6-7-8-9-10 (counting to 10)
Other useful phrases include: baby boy, 2-2-2 (repeating the number 2)
Structures and Functions That Must Be Assessed
It is extremely important that the examination include all structures from the tip of the nose to the larynx and vocal folds. Because flexible endoscopes have a limited field of view, the instrument must be moved from side to side in order to assess both sides and to determine if there is any evidence of asymmetry (a very common finding). Although the examination is called “nasopharyngoscopy,” the examination should include all levels of the pharynx, including the oropharynx, hypopharynx, and larynx. Vocal fold function must be observed, especially in people with velo-cardio-facial syndrome (laryngeal anomalies are common in VCFS). The following structures should be visualized and recorded:
1.The nasal surface of the velum, both at rest and during speech.
2.The size, position and shape of the adenoid.
3.Both lateral pharyngeal walls during speech, both at the level of the velum and below.
4.The posterior pharyngeal wall with special care being taken to look for pulsations of the internal carotid arteries.
5.The palatine tonsils.
6.The lingual tonsil.
7.The pyriform sinuses, vallecula, vocal folds, and surrounding laryngeal structures.
8.The patency of the nasal chamber.
On request, we will make a sample video available for review by the clinicians who will be performing the nasopharyngoscopy.
Reporting of the Results
A standardized method for the reporting of nasopharyngoscopy was published by an International Working Group as reported by Golding-Kushner et al. in 1990. Click on this link for a free reprint of this article from the web site of The Cleft Palate-Craniofacial Journal. Although we will be reviewing the video of the endoscopy, we will be providing a description of the examination using the system outlined in the article.