#speech evaluation

When it comes to the journey of autism, understanding and nurturing communication skills is paramount. A speech evaluation is a pivotal step in unlocking their child's potential for many families. Growing Together Speech is at the forefront of this journey, offering comprehensive Speech Language Evaluations tailored for children on the autism spectrum. We will explore the importance of Speech Evaluation Autism and how to find the right support near you.

Understanding Speech Evaluation for Autism:

Speech evaluations are not one-size-fits-all, especially when it comes to autism. Our evaluations are designed to understand each child's unique communication challenges and strengths at Growing Together Speech. We delve into various aspects of language from articulation to social pragmatics, ensuring a holistic approach. Understanding the nuances of your child's speech patterns is the first step in developing a personalized therapy plan that speaks to their individual needs.

The Growing Together Speech Approach:

We believe in a collaborative and compassionate approach to speech evaluations at Growing Together Speech. Our team of experts specializes in autism, bringing a wealth of experience and empathy to each assessment. We employ the latest tools and techniques to ensure a thorough evaluation, setting the stage for effective, engaging and enjoyable therapy sessions.

Why a Local Speech Language Evaluation Matters:

Searching for speech language evaluation near me brings the convenience and comfort of local support to your doorstep. Proximity means more than just a shorter commute—it signifies ongoing support, community understanding and accessibility. Growing Together Speech is your local ally, ensuring that the path to communication development is a well-supported one.

What to Expect During an Evaluation:

Embarking on a speech evaluation with Growing Together Speech involves a series of engaging activities and observations that help us understand your child's communication capabilities. We look at their ability to understand others, use language effectively and how communicate socially in different settings. Our evaluations are as much about getting to know your child as they are about assessing their speech and language skills.

Post-Evaluation: Crafting the Path Forward:

After the evaluation, the real magic begins. We craft a tailored therapy plan with clear goals and milestones. We are not just about progress; we are about celebrating each victory, big or small, on the road to effective communication at Growing Together Speech.

Conclusion:

A Speech Evaluation Autism is more than just a diagnostic tool—it's a roadmap to your child's success in the world of communication. Growing Together Speech is dedicated to being your partner in this journey, providing expert evaluations and therapy in a nurturing environment. If you are seeking a speech language evaluation near me, look no further. Together, we can help your child's communication skills bloom.

Platysmal Myocutaneous Flap for Reconstruction of T1,T2 Tongue Cancer: Functional Assessment

Authored by Anshuman Kumar

Introduction

The platysma myocutaneous flap (PMF) was first used for intraoral reconstruction in 1978 by Futrell (Futrell et al., 1978) [1]. A platysma myocutaneous flap is a versatile, easy-to-perform, one-stage procedure, and the outcome is best in adequately selected patients, with minimum donor site morbidity. It is large enough to close most head and neck ablative skin or mucosal defects up to 70cm2 and no special equipment is required (Koch, 2002) [2]. The PMF is also an excellent alternative choice to microvascular flaps, especially in patients who are medically unfit for prolonged surgery [3]. But PMF is not as popular as other options of head and neck reconstructive, because of different reasons. The main limitations are lack of bulk, problematic blood supply and unreliability. Also the rates of complications between 10% and 40% have been reported, which includes partial or complete necrosis, fistula, dehiscence, hematoma and infection [4]. The rates of complications have been linked to surgeon’s experience, technique followed and other preoperative factors. In this study we describe our experience with the use of PMF in reconstruction of T1, T2 malignant lesions of tongue. The main objective of our study is to evaluate the feasibility of PMF in tongue reconstruction. And also to evaluate the functional outcome in terms of speech and swallowing, after tongue reconstruction with PMF.

Materials and Methods

In this descriptive study, a total of 75 non-consecutive patients of T1 and T2 tongue cancer, undergoing treatment at Dharamshila Narayana superspeciality Hospital, New Delhi were retrospectively evaluated by collecting data from the period from 2013 to 2016. In our series, newly diagnosed squamous cell carcinoma cases of tongue malignancy of only T1 and T2 lesions with no previous surgery and radiotherapy were included. All patients underwent adequate glossectomy and modified radical neck dissection. Histologically, we confirmed tumor free margin of resection by using a frozen section technique. The size of the flap was designed according to the anticipated defect resulting from the excision of the primary tumor.

Operative procedure

In this descriptive study, a total of 75 non-consecutive patients of T1 and T2 tongue cancer, undergoing treatment at Dharamshila Narayana superspeciality Hospital, New Delhi were retrospectively evaluated by collecting data from the period from 2013 to 2016. In our series, newly diagnosed squamous cell carcinoma cases of tongue malignancy of only T1 and T2 lesions with no previous surgery and radiotherapy were included. All patients underwent adequate glossectomy and modified radical neck dissection. Histologically, we confirmed tumor free margin of resection by using a frozen section technique. The size of the flap was designed according to the anticipated defect resulting from the excision of the primary tumor.

The anticipated skin paddle was outlined in the lower anterio-lateral neck making it an island. The parallel vertical incision was outlined, starting at the chin medially and the tip of the mastoid process laterally with extension of 2 to 2.5cm above the clavicle bone inferiorly. Depend the skin incision of designed skin paddle up to platysma muscle. Complete the neck incision from chin to mastoid tip and up to platysma muscle.Separate the myocutaneous paddle in supra platysmal plane by sharp dissection up to angle of mandible. External jugular vein is isolated for purpose to take it along the flap in subplatysmal plane for adequate venous drainage. Then elevate the paddle of flap in subplatysmal plane in an inferior to superior direction taking care to avoid underlying fat and lymphatic tissue with flap. Meticulous and sharp dissection preferably with bipolar cautery is done while removing submandibular gland and preserve facial vein and facial artery intact with its submental branch which serve as main arterial supply to flap [5] (Figure 1).

Post operatively, patients are evaluated for a period of six months to one year and assessment of tongue mobility, speech, swallowing, and surgical complications of flap as well as neck wound were done.

Speech was evaluated by AYJNIHH 7- point speech intelligibility rating scale [6].

This 7- point rating scale is as follows:

No noticeable differences from normal.

Intelligible though some differences occasionally noticeable.

Intelligible although noticeably different.

Intelligible with careful listening although some words unintelligible.

Speech is difficult to understand with many words unintelligible.

Usually is unintelligible.

Unintelligible.

Swallowing assessment was done by EAT-10 scale [7]. This scale rates swallowing function, based on the patient’s responses to questioning, on scale maximum points of 40. If the EAT-10 score is 3 or higher, it indicates swallowing difficulties. This scale have 10 questions with a score of 0 to 4. The score 0 indicates no problem and score 4 indicates severe problem. As the score increases the severity increases.

The questionnaire is as follows:

My swallowing problem has caused me to lose weight (0-4).

My swallowing problem interferes with my ability to go out for meals (0-4).

Swallowing liquids takes extra effort (0-4).

Swallowing solids takes extra effort (0-4).

Swallowing pills takes extra effort (0-4).

Swallowing is painful (0-4).

The pleasure of eating is affected by my swallowing (0-4 )

When I swallow food sticks in my throat (0-4).

I cough when I eat (0-4).

Swallowing is stressful (0-4).

Tongue mobility is evaluated by asking patient to touch the upper lip, right commisure and left commisure with tip of the tongue. The surgical complications of flap that are assessed, include partial and complete loss of flap, flap detachment, marginal necrosis, fistulisation and partial epidermolysis.

The neck wound healing status is also evaluated as follow: normally healed, wound dehiscence, skin flap necrosis and wound contraction. The criterion used to differentiate between extended or regular wound dehiscence was the presence of a “dehiscent area” ≥ 2cm2. Skin flap necrosis was defined as wide when it affected an area of 2 cm2 or more [7].

Mobility of tongue (To upper lip/Right commissure/Left commissure): Tongue mobility evaluated by asking patient to touch the upper lip, right commisure and left commisure with tip of the tongue.

Results

A total of seventy five patients with T1 and T2 tongue cancer were included in the study. The histologic diagnosis was squamous cell carcinoma in all cases. All patients underwent curative Adequate glossectomy with modified radical neck dissections. Complications of the flap, Status of the neck Flap, Swallowing and speech function and tongue mobility were evaluated 6 months to 1 year postoperatively.

Complications of the flap

Flap complications were noted in 17 patients (22.6%) with complete failure in 2 patients (2.6%), which was managed by complete wound debridment and allowed healing with secondary intension. Partial failure in 5 patients (6.6%) was managed by local measures, such as surgical wound debridement of necrotic tissue. Marginal necrosis and partial epidermolysis is seen in 4 patients (5.3%) and 6 patients (8%) respectively. These complications need prolonged nasogastric nutrition for 15 days (Table 1).

Neck wound complications

Neck wound complications were divided into four categories in which 55(73.3%) cases had normal healing of neck incision flap (Figure 2). Wound dehiscence and skin necrosis reported in 4(5.3%) and 2(2.6%) respectively, required surgical revision. Most of the patients 15(20%) reported with contraction and neck stiffness which was treated by neck physiotherapy (Table 2).

Speech

After excision of primary lesion and platysma flap reconstruction, intelligibility fell to grade 6 in two (2.6%) patient, Grade 5 in three (4%) patient, and grade 4 in five (6.6) patients. More patients showed intelligible although noticeably different in 27(36%) patients and intelligible though some differences occasionally noticeable in 38(50.6%) patients (Table 3).

(“1” = no noticeable differences from normal, “7” = unintelligible).

Swallowing

Mobility of tongue

In these adequate glossectomy patients with platysma flap reconstruction, tongue mobility was evidently recovering, and mostly adequate for producing intelligible speech. Tongue mobility in Upper lip, Right commissure, and Left commissure seen in 47 (62.6%) patients. One side restricted movements mostly towards reconstructed site in 13(17.3%) patients. Two side restricted movements and completely restricted tongue mobility is seen in 9(12%) patients and 6(8%) patients respectively (Table 5).

Discussion

The primary blood supply to PMF derives from sub mental artery which branches from a facial artery and additional blood supply comes inferiorly from the cervical transverse vessels, medially from thyroid vessels and laterally from occipital and postauricular vessels. This is a multiaxial blood supply as it has multiple anastomoses with ipsilateral and contralateral mental, labial and sublingual arteries [8-10].

In our study of the 75 patients we preserve the facial artery and external jugular vein. External jugular vein provides retrograde valve less communication with internal jugular vein through retromandibular and facial venous system, which allows adequate venous drainage.

The experience about reliability of platysma flap is not uniform among the various authors, some author claim excellent results, while others experienced the poor results [11]. Our results showed 77.3% of complete acceptance of the flap (Figure 3-5) while remaining 2.6% shows complete failure(2cases) and 6.6% (5 cases) were partial loss of the flap. Marginal necrosis and partial epidermolysis is seen in 4 patients (5.3%) and 6 patients (8%) respectively. The rates of necrosis of platysma myocutaneous flap found in many other studies ranged from 7.1 to 29.2% [11].

In tongue reconstruction, restoration of speech is an important component. After excision of primary lesion and platysma flap reconstruction, intelligibility fell to Grade 6 in only two (2.6%) of patients, Grade 5 in three (4%) patients, and grade 4 in five (6.6) patients. Majority of patients showed Grade 3 (intelligible although noticeably different) patients and Grade 2 (Intelligible though some differences occasionally noticeable) in patients. Similar results were reported in a study where majority had speech restoration without significant deficits in a month after surgery [12].

Thin and pliability of this flap allows reconstructed tongue with good mobility. Good mobility of tongue is seen in 47(62.6%) patients and restricted tongue mobility is seen in 15(20%).

Conclusion

In conclusion, surgeons should consider the option of using a platysma myocutaneous flap when reconstructing tongue defects. The main advantages are that this flap is readily available, easy to perform, can be obtained during neck dissection and the donor site can be closed in a primary way, with minimal flap complications and good functional outcome. Results can be compared with free flap reconstruction.

Lucian had his speech evaluation last Wednesday. It went well, possibly even better than I expected in terms of him relating with total strangers. The two therapists (physical and speech) came right in and sat down on the floor, pulled out some toys to pique his interest, and started interviewing me. In addition to scripted questions (How is he with other kids? What does he do when he isn’t understood? Can he jump off the ground? Can he take the stairs holding the railing by himself? Does he make silly faces if you do it first?), there were a lot of questions about how “typical” his behavior in that moment would be if they weren’t there. For example, when they tried to get him to walk instead of crawl after a ball, he started crying because he simply doesn’t like being reprimanded. They asked how often these kinds of “fits” pepper our day, and how easily he bounces back afterward. By the end, I was totally drained. Even though I hadn’t felt nervous about the evaluation, coming out of it, I just felt discouraged and defensive. It had nothing to do with the therapists themselves, who were kind and professional. But having to vouch for your kid, trying to portray his behavior objective and thoughtfully, even if it’s a question you’ve never thought of, totally drained me. I was frustrated too, because some of the questions felt like a secret diagnosis--Does he always spend this much time on his stomach? Wait, what? Isn’t tummy time a good thing? Or, So what articles of clothing CAN he manage himself? Only a hat?

He’s definitely eligible for speech, because he’s either behind by 12 months, or hasn’t yet met the milestones of a 12-month-old (It wasn’t clear when they explained it, but either way, he’s eligible). I’ll find out from the written report that comes this week if they recommend any other services. All services are free, they’ll be scheduled as frequently as we want for six months (minimum), and they take place at your home, so of course we’re going to take advantage of any resources offered. But having the sense that my child might struggle to learn filled me with such love and sadness for him. Especially because, at this point in his life, he’s just plain Lucian. Older kids can display hesitancy or lack of motivation or defiance, but a toddler is who he is. And for that little person, so big in his person-ness, to be perceived as not enough is just heartrending.

That was Wednesday, and then came Friday, the day of Lionel’s checkup. I already posted about the lab visit from hell, trying to find his vein and failing. Listening to him scream each time they redirected the needle was positively chilling, and I wanted to curl up in a ball when we were done and drown my sorrows in ice cream. Apart from the legitimate tears from the pain of the needle, to some degree, once he started crying, it didn’t really matter how long we were there. At that point, every new face that tried to comfort him or new hand on his arm, however gentle, just made him angry. As much as I wanted to flee and help him calm down, there was no way I was going to come back and do it all over again. So we muscled through it. And apart from that horrid experience, his doctor’s visit was less than 15 minutes, he’s right on track, and, surprisingly, is in the 95th percentile for height! Lucian was a surprise around 70%, and his brother is following suit. My dad and brother are both over 6-foot, and I think Erik, at 5′5″, is secretly tickled that they inherited tall genes.

Finally, yesterday, Lionel had a dermatology appointment about the birthmarks on his forehead and nose. It was almost a waste of time since there was no immediate outcome, but I suppose information is helpful. Basically, they should fade completely by age 2. If they don’t, a 1-second laser treatment can clear them up. The laser treatment either needs to happen NOW, as in 1) before he gets any tanner from the summer sun, and 2) while he’s small enough to hold still since it would have to be while he’s awake. Otherwise, the treatment needs to wait until he’s 3, when babies can be put to sleep without ill effect. The derm recommended waiting, which I’m happy to do. His birthmark is yet another thing for me to feel defensive about. He’s this perfect baby, the birthmarks just being a part of his precious face, marks I hardly notice anymore, and yet, people fixate. It’s so sad that social pressure kicks in from the moment a baby enters this world. Whether his ears stick out, or his skin has some funny spots, or what have you, it’s not like he has any control over it, or even cares himself, and yet, adults come in and detract from his fleeting perfection by fixating on qualities that deviate ever so slightly from the societal standard.

Anyway, off my soapbox. It was still good to have a documented derm visit on record because there’s a small chance (0.3% to be exact) that Lionel’s salmon patches are actually portwine stains, which ARE a bigger deal and SHOULD be treated right away. In all certainty, since the marks aren’t darker now than when he was born, they’re the regular, benign kind. They’re also not “strawberry patch” birthmarks, which can be treated with a low dosage of blood pressure medication. So again, information is good to have.