Interview with Ann Kummer, Ph.D. CCC-SLP
Share:
Beck: Hi Ann. Thanks for spending a few moments with me today.Kummer:Hi Doug, my pleasure. Thanks for the invitation.Beck:Ann, if you don't mind. Let's start with - where did you earn your bachelor's, master's and doctorate?Kummer:I earned my bachelor's and master's from Indiana University, and my d
Beck: Hi Ann. Thanks for spending a few moments with me today.
Kummer:Hi Doug, my pleasure. Thanks for the invitation.
Beck:Ann, if you don't mind. Let's start with - where did you earn your bachelor's, master's and doctorate?
Kummer:I earned my bachelor's and master's from Indiana University, and my doctorate is from the University of Cincinnati in 1986, and I've actually been at the medical center for just about thirty years.
Beck:Wow - that's fantastic. When did you actually start working on and studying velopharyngeal dysfunction and resonance disorders?
Kummer:Well, my dissertation was on the effect of maxillary advancement on velopharyngeal function, and that was 20 years ago, but I had been focusing on this area for most of my career prior to that.
Beck:Ann, I guess the primary patients we're discussing would be people who have had clefts that were surgically repaired?
Kummer:Generally, yes. Patients with a history of cleft palate are the largest population of people with velopharyngeal dysfunction and resonance disorders. Of course, there are also patients with submucous clefts, and those are more difficult to diagnose as they are less visible on examination. There could also be abnormal adenoid tissue on the pharyngeal wall, unilateral velar paresis or paralysis and other contributing factors as well.
Beck:Forgive me for asking, but would you please review with me, what is the definition of a submucous cleft?
Kummer:Sure. A submucous cleft is when the mucosa within the oral cavity is intact, but the defect is on the nasal surface of the velum. This can affect the insertion of the muscles that would normally raise, or elevate the velum, impacting speech.
Beck:Resulting in velopharyngeal insufficiency?
Kummer:Right, velopharyngeal insufficiency or incompetence.
Beck:OK, I understand a submucous cleft would be more difficult to visualize on exam. So then, how are these detected?
Kummer:Well, it varies. Sometimes you can see it on the oral surface, as it might have a "blue" tint to it, called a "zona pellucida." The blue comes about as there is only a thin mucosal layer without the muscle under it. Another thing to look for is the bifid uvula, or a hypo-plastic uvula.
Beck:It seems that the bifid uvula could be easily visualized if one were so inclined to look, but how do you know when there's a hypo-plastic uvula?
Kummer:Often that can be suspected if the uvula looks short or looks square. Of course, if the oral exam does not reveal the defect, and there is a suspicion of it being present, nasopharyngoscopy can be very useful, too.
Beck:I know some SLPs do perform nasopharyngoscopy. Do you do the exam?
Kummer:Yes, I do it in one of our clinics, and in our other clinic the ENT does it. I've been doing it since the mid-1980s and it is part of our Scope of Practice from ASHA. With adults, it's fairly quick, perhaps 5 minutes or less. Of course with children, it can take quite a bit longer!
Beck:No doubt. After you have the scope in place, what does the patient do?
Kummer:Generally I have them produce particular sentences with certain speech sounds so I can examine and observe velopharyngeal movement, the basic pattern of closure, while also looking for an opening. Of course if I find an opening I document the shape, size location, and probable cause. This dictates the recommended treatment.
Beck:And then the SLP starts their rehabilitative treatment?
Kummer:Yes. Sometimes the submucous cleft is surgically treated, and other times not. Surgical treatment can be as minor as an injection on the posterior pharyngeal wall if there is a very small opening. Other times it may involve actual reconstruction. Overall, surgical treatments are quite successful, particularly in the hands of a surgeon who does a lot of these. Speech therapy is appropriate if the problem is essentially due to misarticulations or there are compensatory articulation productions. Speech therapy does not correct hypernasality and it only corrects nasal emission with this is due to misarticulation.
Beck:What is the primary symptom an adult might have with respect to voice, which indicates that you might want to look for a submucous cleft?
Kummer:Abnormal resonance or nasal emission. If the patient has hypernasality and the cause is undetermined, a submucous cleft is a reasonable thing to rule out. If there is a nasal emission with or without hypernasality, that too, might point me in the direction of a submucous cleft. With a small hole, such as a pin-sized hole, you get a little turbulence. With a medium gap you hear hypernasality and nasal emissions, and with a very large gap you hear hypernasality with weak consonants.
Beck:This is really interesting work, Ann. How many SLPs are involved with this area of expertise?
Kummer:Excellent question. Unfortunately, the answer is less and less all the time. I would guess of the 70 or 80 thousand SLPs across the USA, less than 100 do this type of work. The major problem is that cleft palate is not a required course in many of the graduate programs, and so SLPs have little exposure to this population and their special needs. So in essence, the patient population has increased, and the quantity of SLPs doing this work has decreased. We actually offer a "Master's Class" on cleft palate and velopharyngeal dysfunction at Cincinnati Children's every year to help the SLP get up to speed on these issues from an academic and clinical perspective.
Beck:Very interesting Ann. Thanks for your time and your expertise, this is really fascinating work.
Kummer:Thanks you too, Doug. It's been fun.
----------------------------------
The Master's Class on Cleft Palate and Velopharyngeal Dysfunction will be held on May 12-13, 2006 at Cincinnati Children's Hospital Medical Center.
For more information, please contact: Bridgitt Pauly at bridgitt.pauly@cchmc.org or go to the following website: www.cincinnatichildrens.org/svc/alpha/s/speech/calendar.htm
To learn more about Dr. Kummer's book, please visit www.delmarlearning.com/browse_quicksearch.aspx?search=kummer
Kummer:Hi Doug, my pleasure. Thanks for the invitation.
Beck:Ann, if you don't mind. Let's start with - where did you earn your bachelor's, master's and doctorate?
Kummer:I earned my bachelor's and master's from Indiana University, and my doctorate is from the University of Cincinnati in 1986, and I've actually been at the medical center for just about thirty years.
Beck:Wow - that's fantastic. When did you actually start working on and studying velopharyngeal dysfunction and resonance disorders?
Kummer:Well, my dissertation was on the effect of maxillary advancement on velopharyngeal function, and that was 20 years ago, but I had been focusing on this area for most of my career prior to that.
Beck:Ann, I guess the primary patients we're discussing would be people who have had clefts that were surgically repaired?
Kummer:Generally, yes. Patients with a history of cleft palate are the largest population of people with velopharyngeal dysfunction and resonance disorders. Of course, there are also patients with submucous clefts, and those are more difficult to diagnose as they are less visible on examination. There could also be abnormal adenoid tissue on the pharyngeal wall, unilateral velar paresis or paralysis and other contributing factors as well.
Beck:Forgive me for asking, but would you please review with me, what is the definition of a submucous cleft?
Kummer:Sure. A submucous cleft is when the mucosa within the oral cavity is intact, but the defect is on the nasal surface of the velum. This can affect the insertion of the muscles that would normally raise, or elevate the velum, impacting speech.
Beck:Resulting in velopharyngeal insufficiency?
Kummer:Right, velopharyngeal insufficiency or incompetence.
Beck:OK, I understand a submucous cleft would be more difficult to visualize on exam. So then, how are these detected?
Kummer:Well, it varies. Sometimes you can see it on the oral surface, as it might have a "blue" tint to it, called a "zona pellucida." The blue comes about as there is only a thin mucosal layer without the muscle under it. Another thing to look for is the bifid uvula, or a hypo-plastic uvula.
Beck:It seems that the bifid uvula could be easily visualized if one were so inclined to look, but how do you know when there's a hypo-plastic uvula?
Kummer:Often that can be suspected if the uvula looks short or looks square. Of course, if the oral exam does not reveal the defect, and there is a suspicion of it being present, nasopharyngoscopy can be very useful, too.
Beck:I know some SLPs do perform nasopharyngoscopy. Do you do the exam?
Kummer:Yes, I do it in one of our clinics, and in our other clinic the ENT does it. I've been doing it since the mid-1980s and it is part of our Scope of Practice from ASHA. With adults, it's fairly quick, perhaps 5 minutes or less. Of course with children, it can take quite a bit longer!
Beck:No doubt. After you have the scope in place, what does the patient do?
Kummer:Generally I have them produce particular sentences with certain speech sounds so I can examine and observe velopharyngeal movement, the basic pattern of closure, while also looking for an opening. Of course if I find an opening I document the shape, size location, and probable cause. This dictates the recommended treatment.
Beck:And then the SLP starts their rehabilitative treatment?
Kummer:Yes. Sometimes the submucous cleft is surgically treated, and other times not. Surgical treatment can be as minor as an injection on the posterior pharyngeal wall if there is a very small opening. Other times it may involve actual reconstruction. Overall, surgical treatments are quite successful, particularly in the hands of a surgeon who does a lot of these. Speech therapy is appropriate if the problem is essentially due to misarticulations or there are compensatory articulation productions. Speech therapy does not correct hypernasality and it only corrects nasal emission with this is due to misarticulation.
Beck:What is the primary symptom an adult might have with respect to voice, which indicates that you might want to look for a submucous cleft?
Kummer:Abnormal resonance or nasal emission. If the patient has hypernasality and the cause is undetermined, a submucous cleft is a reasonable thing to rule out. If there is a nasal emission with or without hypernasality, that too, might point me in the direction of a submucous cleft. With a small hole, such as a pin-sized hole, you get a little turbulence. With a medium gap you hear hypernasality and nasal emissions, and with a very large gap you hear hypernasality with weak consonants.
Beck:This is really interesting work, Ann. How many SLPs are involved with this area of expertise?
Kummer:Excellent question. Unfortunately, the answer is less and less all the time. I would guess of the 70 or 80 thousand SLPs across the USA, less than 100 do this type of work. The major problem is that cleft palate is not a required course in many of the graduate programs, and so SLPs have little exposure to this population and their special needs. So in essence, the patient population has increased, and the quantity of SLPs doing this work has decreased. We actually offer a "Master's Class" on cleft palate and velopharyngeal dysfunction at Cincinnati Children's every year to help the SLP get up to speed on these issues from an academic and clinical perspective.
Beck:Very interesting Ann. Thanks for your time and your expertise, this is really fascinating work.
Kummer:Thanks you too, Doug. It's been fun.
----------------------------------
The Master's Class on Cleft Palate and Velopharyngeal Dysfunction will be held on May 12-13, 2006 at Cincinnati Children's Hospital Medical Center.
For more information, please contact: Bridgitt Pauly at bridgitt.pauly@cchmc.org or go to the following website: www.cincinnatichildrens.org/svc/alpha/s/speech/calendar.htm
To learn more about Dr. Kummer's book, please visit www.delmarlearning.com/browse_quicksearch.aspx?search=kummer