Marie Pinkstone MA MRCSLT Lead Speech and Language Therapist

1. AnEarly Report of an MRI Cohort Study of patients with Speech Disorders associated with Velopharyngeal Dysfunction Marie Pinkstone MA MRCSLT Lead Speech and Language Therapist North Thames Regional Cleft Service

2. Research Group • Ethical Approval awarded from Bart's and the Royal London Hospital NHS Trust Ref : 08/H070/30 • R and D Department at GOSH : R and D 12NS03 • Lead Investigator : Professor Malcolm Birch • Ms Marie Pinkstone, Dr Debbie Sell • Mr Brian Sommerlad, Mr Loshan Kangesu,Mr Guy Thorburn, Mr Paul Morris • North Thames Regional Cleft Service, • Dr Marc Miguel, Dr Andrew Scott, Dr MarzenaArridge , Clinical Physics , Barts Health NHS Trust

3. Literature Review • Gold Standard Investigations ( Sell and Pereira , 2011 ) • Videofluoroscopy – multi view • Nasendoscopy • Present with recognized limitations • Uses ionisingradiation

4. Literature Review • Increasing awareness of the benefits of MRI to evaluate speech disorders associated with VPD • MRI has the potential to view the morphology of the soft palate and associated musculature involved in VP closure eg the LevatorVeliPalatini pre and post intervention • One major international research group utilizing MRI have published clinical studies of small numbers of cleft patients (Perry et al 2014) ( Kuehn et al, 2004) (Kuehn et al,2001) • Limited normative data and no paediatric studies reported in the literature ( Perry et al , 2011) • No literature to describe how typical deviant consonant productions associated with the muscles of the velopharynx are made eg nature of nasal fricatives and non oral articulations

5. Literature Review • Research has focused on the development of data acquisition • Number of data acquisition models , • Perry et all ( 2010 ) vowel repetition • Bae et al (2011) focused on voiced fricative – low vowel repetitions • Birch et al ( 2014) morphology of the soft palate • Pinkstone et al ( 2014)

6. Anatomy

7. Adult MRI

8. Speech & Palate MRI: Issues • Best imaging technique for the management of patient with repaired cleft palate • Detailed Anatomy • Real-time imaging during Speech • MRI is slow: can you really do it?

9. AIMS • To develop an MRI acquisition protocol to assess velopharyngeal closure during speech and visualise the associated musculature on a standard clinical scanner

10. Study Design • Prospective cohort study • In collaboration with Bart's and the Royal London • MRI Suite - Clinical Scanner : 1.5T Phillips Archievascanner • Study 1 Protocol development and refined on 20 healthy adult volunteers • Study 2 Protocol tested on clinical population of 10 subjects

11. Study 1 Results • Measurement of LVP morphology satisfactorily undertaken • Significant differences were found between male and female volunteers • LVP origin width • LVP length • LVP width • Results were consistent with other published data

12. Study 2 Subjects • Inclusion Criteria • All patients with VPD over the age of 7 years with no other significant pathology • Patients with suspected levator abnormality and or patients with complex VPD who have had previous unsuccessful surgery, all with a diagnosed (O)SMCP • Presented with the range of speech disorders associated with VPD • Exclusion criteria • All children under the age of 6.11 years, with severe learning or physical difficulties, or significant ill health • All patients with contra-indications for MRI eg Cochlear Implant, dental implants/plates

13. Subjects • Recruitment and consent • From VPI clinics at GOSH and St Andrews • Research SLT contacted families 48 hours after they expressed an interest to join the study

14. Methods • Real time speech assessment ( fast gradient echo sequences 15 frames ) in views similar to videofluoroscopy and nasendoscopy • Imaging during extended phonation • Clinical Test Sentences

15. Speech Sample Speech tasks • Counting 1 -20 x 3 • List GOSPASS sentences • Tim putting a hat on • Daddy mended a door • I saw Sam sitting on a bus • The Zebra is at the zoo • Karen is making a cake • Gary has got a bag of lego

16. Procedure • Positioned in MRI with adapted microphone • Supine • Headphones and audio link • Sound recordings – fibre optic microphone and speech movies created off line

17. MRI Views Oblique Imaging Navigator Plane Mid-Sagittal Imaging Navigator Plane

18. MRI Views

19. Mid Sagittal View

20. Endoscopy View

21. Results • Protocol successfully applied to 10 patients • Anatomy of interest could be visualised from the proton density scanner • Data contributed to Subject diagnosis and management plan • Possible to carry out real time speech sequence examination led by Speech and Language Therapist • In 2 patients image quality was compromised – artifacts • Comparison of lateral x ray and MRI sagittal views undertaken • Consensus judgment using the NTRCS videofluoroscopy assessment tool

22. Discussion and Conclusions • We have developed a comprehensive MRI Protocol, including speech assessment protocol • Successfully applied to patients > 7 years of age • Further data acquisition and analysis continues to finalise transfer to clinical practice

23. Challenges • Age range for compliance • Access to MRI and right scanner • Is the speech sample sufficient ? • Can we ensure the plane / angle is placed correctly? • Do MRI studies replicate the Gold Standards investigations ? • Do the findings from MRI replicate or enhance those from Nasendoscopy ?

24. Acknowledgments • Subjects and their families • Cleft Charity – Bridging the Gap • North Thames Regional Cleft Service • Dr Marc Miguel – Images