Final Flashcards
What are the effects of cleft lip and palate on the articulartion, resonance and phonatory speech subsystems?
Articulation: altered structures such as dentition, lips, and palate can result in compensatory or obligatory articulation
Resonance: a cleft palate can result in hyperresonance prior to surgery and VPI post-surgery, as well as altered nasal passages causing resonance issues
Phonation: ?????
What are the speech characteristics typically demonstrated by children with repaired and unrepaired CL/P?
Audible air emissions or turbulent nasal air emissions on high pressure sounds, weak pressure on sounds, nasal substitutions and compensatory articulation, dysphonia
What are the resonance characteristics typically demonstrated by children with repaired and unrepaired CL/P?
Hyper/hyponasality
What is the primary goal for speech intervention for children before palate repair?
Before the repair, the goal is to facilitate oral airflow, contrasting oral versus nasal airflow to avoid learning compensatory strategies. The goal is to transition from blowing tasks to sound production activities and then begin learning functional words.
What are the primary goals for speech intervention for children after palate repair?
Afterwards, the goal is to fix compensatory strategies the child may have developed.
What are some indicators for further instrumental and medical evaluation by a CL/P team?
If constant therapy and practice does not allow the child to produce oral airflow without nasal occlusion during correct placement of speech sounds, refer for investigation of VP functioning.
What are the intrinsic laryngeal muscles in voice and swallowing? Give the action and the innervation of each.
Thyroarytenoid: shortens and tenses vocal folds
Posterior cricoarytenoid: opens vocal folds
Lateral cricoarytenoid: closes vocal folds
Arytenoid: closes vocal folds
Cricothyroid: lengthens vocal cords
What are the extrinsic laryngeal muscles in voice and swallowing? Give the action and the innervation of each.
Thyrohyoid: decreases the distance between the thyroid cartilage and hyoid bone.
Sternothyroid: places a downward pull on the hyoid bone.
Inferior constrictor: moves sidewall of the lower pharynx inward and decreases the size of the pharyngeal lumen.
What are the five layers of the vocal folds, from out to in?
Stratified squamous epithelium Superficial lamina propria Intermediate LP Deep LP Thyroarytenoid
What are included in the body, the transition and the cover of the vocal folds made of?
Cover = stratified squamous epithelium + superficial LP Transition = Intermediate LP + deep LP Body = thyroarytenoid muscle
What is the myoelastic-aerodynamic theory?
When the vocal folds are moved into the airway by the intrinsic laryngeal muscles, they create resistance to air passing through. The air pressure builds and eventually overcomes this resistance, pushing through and causing them to vibrate due to their elasticity.
How does the bernoulli effect factor into the myoelastic-aerodynamic theory?
The small space between the fold when they are adducted causes air to move more quickly between them, resulting in reduced air pressure between the folds. This causes the folds to pull back towards each other, slamming shut. In combination with the myoelastic-aerodynamic theory, this creates the wave pattern of the folds opening and shutting to create phonation.
What are the 4 major divisions of the auditory system?
Outer ear
Middle ear
Inner ear
Central auditory system
What are the main anatomical structures of the outer ear?
Auricle (pinna)
Enternal auditory meatus (ear canal)
Tympanic membrane (ear drum)
What are the main anatomical structures of the middle ear?
The ossicles (stapes, malleus, incus)
What are the main anatomical structures of the inner ear?
Cochlea
Vestibular system
What is the cranial nerve responsible for hearing and balance?
The vagus nerve (VIII), which originates in the medulla, is responsible for hearing and balance.
Name the major nuclei and synapses involved in the ascending auditory pathway.
Brainstem -> synapse on the ventral and dorsal cochlear nuclei -> (some fibres cross midline) -> synapse on superior olivary complex -> nucleus of the lateral lemniscus -> inferior colliculus (connected by fibres that cross over from both sides of the brain stem) -> medical geniculate body (MGB) -> fans out into the auditory radiations to the auditory cortex
Name some disorders of the outer ear.
Microtia Atresia Stenosis Collapsing ear canals Foreign bodies Otitis Externa (swimmers ear) Otomycosis Tympanic membrane perforation
List the cause/what is it, symptoms, effect on hearing, and treatment/considerations for: microtia.
Cause: small ear size resulting from an inherited trait disorder or interrupting in development
Effects on hearing: potentially none in isolation
Treatment: Surgery
List the cause, symptoms, effect on hearing, and treatment/considerations for: Atresia
Cause: no ear canal formed
EOH: Permenant conductive hearing loss (50-60dB)
Treatment: Surgery
List the cause, symptoms, effect on hearing, and treatment/considerations for: stenosis
Cause: narrowing of the ear canal
EOH: some hearing loss
Treatment: hearing aids
List the cause, symptoms, effect on hearing, and treatment/considerations for: collapsing ear canals
Cause: Canal fold in on itself due to weak tissue
EOH: temporary conductive HL (5-50dB)
Treatment: use in-ear headphones to avoid collapse during hearing tests due to weight of head phones
List the cause, symptoms, effect on hearing, and treatment/considerations for: foreign bodies
Cause: Wax
EOH: mild to moderate conductive hearing loss
Treatment: cleaning and removal
List the cause, symptoms, effect on hearing, and treatment/considerations for: Acute Otitis Externa (swimmer ear)
Cause: bateria enters the ear canal and sits there, growing and resulting in an infection.
Symptoms: stenosis caused by cartilage inflammation, tenderness to the pinna, whitish, watery discharge
EOH: decreased hearing
Treatment: topical drops
List the cause, symptoms, effect on hearing, and treatment/considerations for: Chronic Otitis Externa
Cause: same as AOE
Symptoms: dermatitis of the EAM, itchy but less pain, red, scaly skin, may see complete occlusion of the meatus with discharge
EOH: decreased hearing
Treatment: topical drops
List the cause, symptoms, effect on hearing, and treatment/considerations for: otomycosis
Cause: fungal infection cause by overuse of ear drops
List the cause, symptoms, effect on hearing, and treatment/considerations for: tympanic membrane perforation
Cause: excessive fluid in the middle ear, implosion by blow to the head, diving, or waterskiing, punctured, loss of TE
EOH: determined by the location and size but typically mild conductive loss
Treatment: can heal on it’s own or surgery for large repair
What are some disorders of the middle ear?
Otitis Media Tympanosclerosis Exostoses (surfer's ear) Osteoma Otosclerosis Cholesteatoma Discontinuity of the ossicular chain Bell's Palsy
List the cause, symptoms, effect on hearing, and treatment/considerations for: Otitis media
Cause: inflammation of the middle ear, usually resulting from poor ET function. OME is inflammation with fluid but no infection
Symptoms: Otorrhea (discharge from the middle ear)
EOH: amount of fluid determines the degree of hearing loss. Conductive ranging from mild to moderate (50dB) with average being around 20-25dB.
Treatment: spontaneously clears up or insertion of ET tubes
List the cause, symptoms, effect on hearing, and treatment/considerations for: tympanosclerosis
Cause: Scarring on the TM from chronic inflammation, trauma, or ventilation tubes resulting in stiffening of the ossicles or fixation of the ossicular chain
EOH: Conductive loss to varying degrees
List the cause, symptoms, effect on hearing, and treatment/considerations for: Exostoses
Cause: irregular bone growths producing round nodules with a wide base of bone covered by skin
EOH: conductive loss if it occludes the ear canal
Treatment: surgery
List the cause, symptoms, effect on hearing, and treatment/considerations for: Osteoma
Cause: benign tumor, usually unilateral at the cartilage bony junction
EOH: conductive loss if it occludes the ear canal
Treatment: surgery
List the cause, symptoms, effect on hearing, and treatment/considerations for: osteosclerosis
Cause: bony growth at the footplate of the stapes, usually in both ears
EOH: starts as mild to moderate conductive (Carhart notch on audiogram) but flattens out as the footplate becomes more fixed
Treatment: surgery to remove the damaged portion and place it with a prosthesis (stapedectomy) although might have HL after due to regrowth or fistula in membrane covering oval window
List the cause, symptoms, effect on hearing, and treatment/considerations for: cholesteatoma
Cause: skin growth in the middle ear behind the TM usually associated with chronic suppurative OM or marginal perforations
Symptoms: Otorrhea, vertigo, tinnitus, pain, headaches, facial nerve paralysis, and ET dysfunction
EOH: hearing loss
Treatment: surgery, may have to remove middle ear bones resulting in permanent conductive HL
List the cause, symptoms, effect on hearing, and treatment/considerations for: discontinuity of ossicular chain
Cause: congenital defects, skill trauma, and middle ear disease, common in incudostapedial joint.
EOH: moderate to moderate-severe (40-60dB) conductive flat
Treatment : surgery
List the cause, symptoms, effect on hearing, and treatment/considerations for: Bell’s palsy
Cause: facial nerve disorder
Symptoms: facial weakness, sensitivity to noise, facial droop
What are some disorders of the inner ear?
Presbycusis
Congenital hearing loss
List the cause, symptoms, effect on hearing, and treatment/considerations for: Presbycusis
Cause: age related hearing loss
Symptoms: gradually progressive, tinnitus, personality changes, irritable, reduced attention and alertness, lower emotional and intellectual strengths, loss of memory
EOH: generally have a sloping bilateral loss starting with >2000Hz and progressing to lower frequencies
Treatment: amplification if speech is okay when amplified
List the cause, symptoms, effect on hearing, and treatment/considerations for: congenital hearing loss
Cause: genetic, environmental or unknown, syndromic or non-syndromic, autosomal recessive or autosomal dominant
What are the different versions of OM based on length?
Acute: 3 week rapid onset and resolution within 7-14 days
Subacute: persists 4-8 weeks
Chronic: slow onset and lasts >9 weeks
Recurrent: 3 or more episodes with 6 months
What are the different types of OM based on fluid?
Serous: middle ear fluid without bacteria/debris and without associated symptoms accept conductive hearing loss (OME)
Suppurative: fluid with bacteria and debris, most often with AOM and COM (use amoxicillin to kill bacteria and ET to clear the fluid)
What are some general considerations for hearing regarding medication?
Some drugs are known to cause temporary damage such as salicylate pain relievers (aspirin), quinine (malaria medication), and loop diuretics (certain heart/kidney conditions). Some drugs can cause permanent damage to the inner ear hair cells, such as -mycin family (ear infections) and certain cancer treatments and chemotherapies (cisplatin and carboplatin)
What is the basic procedure for assessing hearing?
Otoscope to look at the ear canal
Tympanography to look at the ear drum movement
Audiogram: whether you use insert ear phones
Name some of the roles of SLPs in assessing and managing swallowing.
Identifying the signs and symptoms
Identifying normal and abnormal swallowing anatomy and physiology
Performing, analyzing, and integrating information from non-instrumental and instrumental assessments
Providing safe and effective treatment
Providing education and counselling
Advocating for services of individuals with swallowing and feeding disorders
What are some complications of dysphagia?
Airway obstruction or choking Aspiration pneumonia Dehydration Malnutrition Risk associated with tube feeding Increased length of stay in hospital
What are some neurogenic risks associated with dysphagia?
Stroke
TBI
Dementia
Parkinsons
What are some mechanical risk factors associated with dysphagia?
Acute inflammation (strep throat)
Trauma
Carcinoma
What are some Latrogenic risk factors associated with dysphagia?
Medication induced
Post-surgical complication
Radiation
What are some medication risk factors associated with dysphagia?
Xerostomia (anti-depressants)
Dystonia (neuroleptics)
Increased salivation (clonazepam)
What are some important aspects of medical history to consider in a swallowing assessment?
Congenital family illnesses Neurologic and psychiatric disease Surgical procedures Cancer Systemic/metabolic disorders Respiratory impairments Esophageal issues Investigations (CT, radiographic, etc.)
What are some important aspects of swallowing history to consider during a swallowing assessment?
Patient and family reports Medical history verification Chief complaint Problem localization Specific foods Regurg and reflux Neurologic status Vocal changes Respiration Dental complaints
What are the major components of a bedside swallowing assessment?
Referral for swallowing assessment (why?) Reviewing the medical chart Consulting with the team Introductions Consent History of dysphagia Physical exam Trial feeding Clinical impressions Recommendations Plan
What are some oral signs of dysphagia?
Facial drooping/drooling Food/fluid falling from mouth Difficulty moving food in mouth Inadequately chewed food Pocketing
What are some pharyngeal signs of dysphagia?
Throat clearing/coughing Wet/gurgly voice Choking Complains of food sticking in throat Changes in respiratory status during/post meals
What are some signs of dysphagia aside from oral and pharyngeal signs?
History of swallowing difficulties History of aspiration pneumonia or recurrent lower respiratory infections Complaints of pain while swallowing Mouth odour Weight loss
Compare penetration and aspiration.
Penetration: entry of food or liquid into the larynx at some level down to, but not below, the true vocal folds
Aspiration: entry of food or liquid into the airway, below the true vocal folds.
What are the main cranial nerves associated with swallowing? Provide the name, number, action, and origin.
Trigeminal (V) -> pons (both) Facial (VII) -> pons (both) Glossopharyngeal (IX) -> medulla (both) Vagus (X) -> medulla (both) Hypoglossal (XII) -> medulla (motor)
What are the different phases of swallowing? Give a brief description of each.
Oral prep: food manipulation and mastication
Oral phase: voluntary phase of swallowing where the tongue propels the bolus posteriorly until swallowing is triggered
Pharyngeal phase: reflexive swallow arrived the bolus through the pharynx
Esophageal phase: reflexive esophageal peristalsis carries bolus through the cervical and thoracic esophagus into the stomach.
Describe the key events during normal swallowing. Indicate which are also airway protection steps.
Mastication/bolus prep -> posterior lingual propulsion (AP) -> swallow triggered -> velar elevation (AP) -> laryngeal vestibule closure (AP) -> pharyngeal constriction and elevation (AP) -> UES opening (AP)
What occurs during the oral prep phase of swallowing?
When the bolus enters the mouth, information about the size (CN V), consistency (CN V) and taste (CN VII + IX) is provided by the sensory receptor and salivary glands. Salivation is triggered by the taste receptors on the anterior 2/3 of the tone and the master, temporal, and medial+lateral pterygoids help in mastication. Once the taste and sensation have been achieved, we go through 5 steps: labial seal, buccal and facial tone, adequate and appropriate tonge movements, lowering of the velum+raising of the posterior tongue, and mastication of material with lateral and rotary motion of the mandible.
What actions does the trigeminal nerve provide?
Motor: jaw, hyoid, and palate
Sensory: general sensory for anterior 2/3 tongue, palate, and face
What actions does the facial nerve provide?
Motor: lips, face (facial expressions) and hyoid
Sensory: taste and 2/3 tongue, also triggers salivation
What actions does the glossopharyngeal nerve provide?
Motor: stylopharyngeus
Sensory: general sensory and taste for posterior 1/3 tongue, general sensory for the nasopharynx
What actions does the vagus nerve provide?
Motor: intrinsic laryngeal muscles and some of the esophagus
Sensory: general sensory for larynx and esophagus and taste for epiglottis
What actions does the hypoglossal nerve provide?
Motor: tongue muscles except for palatoglossus
What occurs during the oral phase of swallowing?
The tip of the tongue raises to touch the alveolar ridge with the posterior tongue dropping down to open the oral cavity as the soft palate elevates. The tongue-palate contact gradually increases as the tongue surface moves upwards, pushing the bolus back. When the bolus hits the faucial pillars, the swallow is triggered. The hyoid moves up and forward, pulling the larynx and the pharynx upwards.
What muscles are involved in the oral prep phase of swallowing? Give the name, the action, and the innervation.
Orbicularis fris (CN VII): close the lips Buccinators (CN VII): aid in chewing, tenses cheeks, and closes the mouth
What muscles are involved in the oral phase of swallowing? Give the name, the action, and the innervation.
Levator palatini (X): raises the soft palate and closes the nasal cavity
Hyoglossus and styloglossus (XII): posterior tongue depression
Superior pharyngeal constrictor (X): closure of the nasopharynx and contraction of the pharynx
Mylohyoid (V): hyoid bone elevation
Stylohyoid (VII): draws hyoid back and elevates the tongue
Geniohyoid (XII): hyoid bone elevation
What muscles are involved in mastication? Give the name, the action, and the innervation.
Masseter (V): elevates mandible, closing the jaw
Temporalis (V): elevates and retracts the mandible, closing the jaw
Medial ptergoid (V): raises the mandible against the maxilla, closing the jaw
Lateral pterygoid (V): draws the condyle and articular disk forward, helping in opening the mouth
What muscles are involves in the pharyngeal phase of swallowing? Give the name, action, and innervation.
Lateral circoarytenoid (X): adducts vocal folds
Transverse arytenoid (X): adducts vocal folds
Thyroarytenoid (X): narrows laryngeal inlet, helping close off the airway
Palatopharyngeal (X): elevates the pharynx
Thyroid (XII): depresses the hyoid and elevates the larynx
Cricopharyngeus (IX & X): contracts at rest to prevent reflex, then relaxes during swallowing to allow bolus passage
What are the muscles of the pharynx? Give the name, action, and innervation.
Superior, middle, and inferior constrictor (X): constriction of the pharynx
Saplingopharygus and palatopharygeus (X): Shoetening and elevation of pharynx
Stylopharyngeus (IX): shortening and elevation of pharynx
Describe the pharyngeal phase of swallowing.
The bolus is propelled posteriorly by the tongue and hits the faucial pillars. The supra hyoid contracts, raising the hyoid. The epiglottis inverts to protect the airway. The pharyngeal muscles contract, raising the pharynx. The tongue base retract to the posterior pharyngeal wall and the pharyngeal constrictors are activated, creating a descending wave to push the bolus down. The thyrohoid contracts, moving the larynx towards the hyoid. This laryngeal/pharyngeal raising pulls the cricoid away from the PPW and opens the UES. The bolus passes through into the esophagus.
What are the 3 ways the UES opens?
When the larynx elevates, it pulls the cricopharynxgeus, loosening the opening
The intrabolus pressure helps drive the bolus through
The closure of the larynx creates a negative pressure in the pharynx, sucking the bolus down and driving the UES open
What can alter the timing of the pharyngeal phase?
The taste, texture, and volume of the bolus gathered prior to the motor response.
How is the larynx protected during swallowing?
Epiglottic deflection, vocal fold adduction, laryngeal elevation, and hyoid elevation
