Lectures 17-? Flashcards
~Basic Definitions~
Resonance:
Voice:
Adduction:
Abduction:
Resonance: The quality of the voice that is produced from sound vibrations in the pharyngeal, oral, and nasal cavities
Voice: The complex, dynamic product of vocal fold vibration that allows us to vocalize and verbalize.
Adduction:The state in which the vocal folds must are closed (active)
Abduction: The state in which the vocal folds are open (at rest)
Velopharyngeal dysfunction (VPD) definition:
Failure of the velopharyngeal mechanism to separate the oral and nasal cavities during speech and swallowing
~Pitch Terms~
Habitutal Pitch:
Optimal Pitch:
Basal Pitch:
Ceiling Pitch:
Vocal Range:
Habitual Pitch: average speaking voice
Optimal Pitch: natural, comfortable voice
Basal Pitch: lowest pitch in habitual voice
Ceiling Pitch: highest pitch in habitual voice
Vocal Range: continuous voice from lowest to highest pitch
~Vocal Pitch~
- Frequency of the voice constantly varies during speech
- Monotone voice: Result of not varying habitual speaking frequency
- Varying pitch has linguistic significance
- Modifications in length and tension of the
vocal folds are necessary to produce
pitch change
Measured in hertz (Hz): the number of complete vibrations/ second
Perceptual correlate – Fundamental
Frequency (FO):
F0 for men is
F0 for women is
F0 for children
Perceptual correlate – Fundamental
Frequency (FO): associated with RATE of vocal fold vibration
F0 for men is around 125 Hz
F0 for women is around 250 Hz
F0 for children can be up to 500 Hz
Vocal Loudness
-Perceptual correlate of intensity
-Measured in decibels (dB) -Conversational speech
averages around 60 dB
-Alveolar pressure is the major
determinant of vocal intensity
~Normal lifespan issues; voice quality~
Presbyphonia:
Women:
Men:
Laryngeal cartilages and joints begin to ossify or calcify around the third (men) and fourth (women) decades
- Presbyphonia: Voice disorder characterized by perceptual changes in pitch, pitch range, loudness, and voice quality in older individuals
- Menopause and hormone-related factors causing edema may be responsible for the change in women (lowered F0)
- For men, age-related changes to laryngeal muscle due to atrophy may be responsible for increased F0 in older men
~Normal Lifespan Issues; Resonance~
-Closure patterns may vary among individuals and can change over time
-Young children with adenoidectomy may have to change their closure patterns
-Velopharyngeal function during speech production remains intact and unchanged from young adulthood through advanced age
~Risk Factors for Voice Disorders~
Adults:
Children:
Adults:
-Specific vocal behaviors such as loud talking, coughing, or throat clearing may predispose some individuals to voice disorders
-Women are more often affected than men
-When resonance, pitch, loudness, or general phonatory quality lasts for longer than 2 weeks
Children:
-In children 3-10 years old, prevalence of voice disorders is about 6% with boys affected more often
-Voice disorders in children are usually related to vocal misuse/abuse and are typically temporary
-“yells, screams, or cries frequently” -“loses his/her voice every time s/he has a cold”
-“uses a lot of effort to talk”
Vocal Disorder:
When one or more perceptual aspects of voice such as pitch, loudness, or voice quality are outside the range of normal for an individual’s age, sex, cultural background, or geographic location
~Structural Voice Disorders; Vocal Polyps~
What is it?
~Kinds~
Sessile Polyps:
Pedunculated polyps:
Symtoms:
What is it?
-Fluid filled lesions when blood vessels rupture & swell
Tend to be unilateral, larger than nodules, prone to hemorrhage Can result from single traumatic event Sensation of something in throat Surgical removal & Voice Therapy
~Kinds~
Sessile Polyps: closely adhere to vocal folds & can cover 2/3 of vocal fold
Pedunculated polyps: appear attached to vocal fold by means of a stalk
Symtoms: hoarseness, breathiness, & diplophonia
~Structural Voice Disorder; Constance ulcers and granulomas~
What is it?
Causes:
Symptoms:
What is it?
* Contact Ulcers are small, reddened ulcers on the posterior surface of the vocal folds in the region of the arytenoids
* Usually bilateral & painful
* Change/replaced by granulated tissue called a granuloma
Causes:
* GERD
* Trauma from intubation
Symptoms:
* Hoarseness
* Breathiness
* Throat clearing
* Vocal fatigue
* May reappear after removal
~Structural Voice Disorders; laryngeal webs~
What?
Causes:
Symptoms:
Treatment:
What?
Result of connective tissue growth
between vocal folds
Causes:
*Congenital or acquired
Symptoms:
* Interferes with breathing
* Stridor
* Shortness of breath
* Produces high- pitched, hoarse quality or absence of voice
Treatment:
* Must be surgically removed
~Neurological Voice Disorders; Vocal fold paralysis~
Cause:
Results:
Unilateral vocal fold paralysis:
Bilateral vocal fold paralysis:
Treatment:
Cause:
-Damage to CN X (vagus nerve)
-Recurrent laryngeal nerves supplies the laryngeal muscle for voice activation
Results:
-Risk of aspiration – vocal folds are not protecting the airway if abducted
Unilateral vocal fold paralysis:
-hoarse/breathy voice
-reduced loudness
-monoloudness
-pitch breaks
-diplophonia
Bilateral vocal fold paralysis:
-breathy voice
-weak voice or absent voice
Treatment:
-Surgical intervention Voice Therapy after surgery
-Goal to increase vocal fold closure & loudness
~Neurological Voice Disorders; Parkinson Disease~
Cause:
Characteristics:
Treatment:
Cause: Degeneration of dopaminergic neurons in the substantia nigra interfering with the function of the basal ganglia
Characteristics:
-Muscle rigidity
-Reduced range of motion
-Tremor at rest
-Hypokinesia
-No facial movement
-Reduced loudness
-Monopitch
-Monoloudness
-Hoarseness
-Harshness
-Breathiness
Treatment:
Deep brain stimulation Speech Therapy for Voice Goal: to increase
vocal fold adduction to improve loudness and intelligibility
~Functional Voice Disorders; muscle tension dysphonia~
Causes:
Symptoms:
Treatment:
Causes: Abnormal muscle activity in the absence of structural or neurological abnormalities
Symptoms:
-Hoarseness
-Strained harshness
-Strained breathiness
-Aphonia
-Intermittent pitch breaks
Treatment:
-Speech Therapy for hyperadduction
~Functional Voice Disorders; conversation aphonia~
Causes:
Symptoms:
Treatment:
Causes:
Suppressed, strong emotions Vocal folds are not approximating for speech production
Symptoms:
Coughing & throat clearing
Treatment:
Will persist until person is willing To resolve emotional conflict Psychologist referral
~Functional Voice Disorders; mutational falsetto AKA puberphonia~
What?
Treatment:
What?
-Continual use of high-pitched voice by adolescent or adult males who have gone through puberty
Treatment:
-Most benefit from behavioral voice therapy to lower pitch
Psychological referral
~Resonance Voice Disorders~
Causes:
~Types~
Hyponasality:
Denasality:
Hypernasality:
Symptoms:
Causes:
-Structural abnormalities
-Cleft palate
~Types~
Hyponasality:
Blockage in the nasopharynx that impedes sound from traveling through the nose for production of nasal sounds i.e., m/n/ng
Denasality:
Complete blockage of the nasopharynx
Hypernasality:
-Velopharyngeal mechanism fails to decouple the oral and nasal cavities
-Secondary to Velopharyngeal dysfunction
Symptoms:
-Audible nasal emission
-Nasal rustle
-Nasal turbulence
~Assessment for voice disorders~
Auditory-perceptual evaluation:
Visipitch Equipment:
Voice handicap index:
Overall Assessment:
Auditory-perceptual: evaluation to describe pitch, loudness, and voice characteristics
May include detailed acoustic and physiological measurements with Visipitch Equipment
The Voice Handicap Index can help determine the psychosocial effects of a voice disorder
Case History
Clinical Observation
Description of the voice problem
When it started
Duration
What the client believes might be causing it
How it affects daily life
Person’s social and vocational use of the voice
Overall physical and psychological condition
~Other voice Instrumentation~
Nasometer:
Multi-view videofluorscopy:
Videonasendoscopy:
Nasometer:
* Measured the relative amplitude of acoustic energy being emitted
through the nose and mouth during phonation
* Nasalance score is computed to reflect the magnitude of hypernasality
Multi-view videofluorscopy:
* Motion picture X-ray recorded on DVD
* Permits imaging of velopharyngeal function from three different
perspectives
Videonasendoscopy:
* Also known as fiberoptic nasendoscopy
* Lens, fiberoptic light cable, insertion tube, camera, and connection to a monitor
~Treatment Approaches for Benign Structural Abnormalities~
- Voice therapy is the clinical method of choice for vocal misuse/abuse
- Taught to modify vocally abusive behaviors
- Educated about laryngeal pathology
- Goal is to teach the client to eliminate vocally abnormal or abusive behavior by producing a voice that balances respiratory, laryngeal, and articulatory/resonatory subsystems
~Treatment Approaches for Resonance Disorders~
Medical Management:
Prothetic Management:
* Palatal obturator
* Speech bulb obturator
* Palatal lift
Medical Management:
* Children born with palatal clefts undergo surgical closure between 9
and 18 months of age
* Surgery to repair cleft lip occurs before 3 months of age
Prothetic Management
* Palatal obturator: Similar to a retainer; can cover a fistula until
further surgery is warranted
- Speech bulb obturator: Can be used when the velum is too short to
contact the posterior pharyngeal wall or when it is immobile - Palatal lift: Used when the velum is immobile
~Treatment Approaches for Resonance Disorders~
Behavioral Management:
Electropalatograohy (EPG):
Behavioral Management:
* May be appropriate for individuals with VPI resulting in mild hypernasality after surgical repair of a cleft palate
* Continuous positive airway pressure (CPAP) can be used to strengthen muscles of the velum
* Based on exercise physiology principle of progressive resistance training
Electropalatography (EPG):
* An artificial palate plate containing electrodes connected to a computer is used to determine when the tongue contacts the electrodes
* Can be used to learn correct placement of articulators
~Treatment Approaches for Resonance Disorders~
Treatment of Articulation Disorders Secondary to VPD:
Treatment of Articulation Disorders Secondary to VPD:
* Direct intervention for speech-sound development should begin prior to the first palatal surgery, around 5-6 months
* Early intervention should focus on increasing consonant inventory,
pressure consonants (stop/plosives e.g., p/b) and increased oral airflow
* Teaching the difference between oral and nasal sounds, as well as how to direct airstream through the mouth (using a nose clip) may be helpful
* For children who substitute glottal stops for high-pressure consonants, direct treatment should begin as soon as possible
~Transgender~
Females transitioning to males:
Males transitioning to female:
Females transitioning to males:
-Hormone replacement lowers pitch
Males transitioning to female:
* Need assistance in
raising vocal pitch to 155-165 Hz or up to 180 Hz
* Anterior tongue placement creates a more “forward” resonance associated with the female voice
Is Voice/Resonance Treatment Effective?
-Treatment is reasonably effective for voice disorder associated with vocal misuse and abuse, some disorders associated with neurological conditions like Parkinson disease, and voice disorders associated with psychological or stress conditions
-Changing habituated behaviors that contribute to vocal misuse or abuse is hard work and takes time
-Individuals born with cleft palate who receive medical and behavioral intervention earlier in life generally speak normally by the time they are adolescents
~Prevalence and Incidence; Fluency Disorders~
* Fluency disorders have a prevalence rate of about ________ an incidence rate of about _________
- _____% of people have stuttered sometime in their lives, but only ______% of those are currently suffering.
- Lifetime incidence is as high as ____
- Onset of stuttering may be sudden and
distinct for as many as ______ of children - _____ of children under 10, as compared to _____ of adolescents have a fluency disorder.
- ______ of children recover within the first 2 years after ons
- ______ will recover within the next few years
- Fluency disorders affect relatively few individuals, with a prevalence rate of about 1 in 100 persons and an incidence rate of about 5 in 100 persons.
- 5% of people have stuttered sometime in their lives, but only 1% of those are currently suffering.
- Lifetime incidence is as high as 8%
- Onset of stuttering may be sudden and distinct for as many as
36% of children - 1.5% of children under 10, as compared to .5-.7% of
adolescents have a fluency disorder. - ~70% of children recover within the first 2 years after ons
- 85% will recover within the next few years
Stuttering: Core Behaviors:
- Repetitions of sounds, syllables, or one- syllable words
- Prolongations of sounds or blocks (no sound)
- More than 2 repetitions of a sound or
word is considered a stuttering moment - 1or 2 repetitions of an interjection is generally considered a normal dysfluency
* MORE than 2 repetitions of an injection is equated with stuttering - Clustered dysfluencies (more than one dysfluency in a word) are common in young children and may indicate developing stuttering
Stuttering: secondary behaviors/ characteristics
- Eyeblinking
- Facial grimacing or tension
*Exaggerated movements of the head, shoulders, and arms - Interjected speech fragments (“…that is to say…”)
- Repetitive habits
*Habits adopted in an effort to reduce instances of stuttering - EscapeBehaviors
- Avoidance Behaviors
* Word and sound avoidance
* Circumlocution
* Situation avoidance - Feelings and Attitudes
Neurogenic Stuttering:
-Associated with
-usually occurs on:
-do not exhibit:
-stuttering events are:
-does not improve with:
-Associated with neurological disease or trauma and is acquired after childhood
-Usually occurs on function words – auxiliary verbs (to show tense), prepositions, articles, conjunctions, and pronouns
-Do not exhibit any secondary behaviors, or fear/anxiety about speaking
-Stuttering events are widely dispersed through the utterance
-Does not improve with repeated reading or singing
~Developmental Stuttering~
Begins in:
Occurs on:
- Most common
- Begins in Preschool Years
- Onset between 2 and 5 years old
- Gradual increase of severity with age
- Occurs on content words (nouns, verbs, adjectives, and adverbs)
- Occurs on the initial syllable of words
~Developmental Stuttering; younger preschool 2-3 years old~
Periods of:
Stutter when:
Sound and syllable repetitions:
Stuttering Occurs:
- Periods of stuttering followed by periods of relative fluency
- Stutter when upset or excited or under pressure
- Sound and syllable repetitions are dominant
- Stuttering occurs at beginning of sentences, clauses, and phrases on content and function words (auxiliary verbs to show tense, prepositions, articles, conjunctions, pronouns)
- Not aware of problem
- No secondary behaviors
~Developmental Stuttering; preschool 4-5 years old~
Secondary Behaviors:
Stuttering begins to sound:
Blocks:
Events:
Aware:
- Secondary behaviors, fear and/or anxiety about speaking may appear
- Stuttering begins to sound rapid and irregular
- Blocks may begin to appear
- Events more widely dispersed throughout an utterance
- Aware of problem
- May become frustrated
~Stuttering through the lifespan; school age~
Secondary behaviors:
Stuttering appears:
Certain words:
Blocks:
Excessive:
- Secondary behaviors and circumlocution become apparent
- Fear and avoidance of stuttering begin
- Stuttering appears to be in response to
specific situations - Certain words are regarded as more difficult and are avoided
- Blocks are more common than repetitions and prolongations
- Excessive muscular tension
~Stuttering through the lifespan; older teens and adults~
Stuttering is:
Certain sounds:
Longer tense blocks:
Repetitions:
Secondary Behaviors:
Evidence of:
- Stuttering is in its most advanced form
- Individual has developed a self-concept as a person
- Vivid and fearful anticipation of stuttering
- Certain sounds, words, and speaking situations are feared/avoided who stutters
- Longer, tense blocks are the core stuttering behavior
- Repetitions still occur but are more rapid and irregular and may co-occur with blocks
- Secondary behaviors and circumlocution continue
- Evidence of embarrassment, helplessness, fear, and shame
~Theories~
Organic Theory:
Behavioral Theory:
Psychological Theory:
Organic Theory:
* Proposes an actual physical cause
* Due to findings of structural & functional differences in the brains of adults with chronic developmental stuttering (Cerebral dominance theory)
Behavioral Theory:
Asserts that stuttering is learned response to external conditions Parents react negatively to normal dysfluencies & cause anxiety that leads to increased stuttering (Diagnosogenic theory)
Psychological Theory:
Contends stuttering is a neurotic symptom
Treated by psychotherapy
~Procedures~
Most Important:
Most important – observation of speaking; detailed interview
-detailed analysis of speech behaviors
-standardized tests are very helpful
-determine the average number of disfluencies
-measure the units that occur in each repetition
-determine feelings and attitudes about stuttering
Diagnosis of Stuttering
- After the clinician administers a comprehensive fluency assessment, a diagnosis is made, based on all of the accumulated evidence. As a general rule, a fluency disorder is more likely to be diagnosed when the following are observed during assessment:
* Ten or more total disfluencies in 100 words
* Three or more stuttering like disfluencies in 100 words
* Physical escape behaviors
* Verbal avoidance behaviors
~Prognosis-Intervention; stuttering~
School-aged children:
Adolescents and Adults:
School-aged children:
*Various treatment approaches and techniques are effective, but the ability to use these techniques in a variety of settings can be problematic
*Address psychosocial aspects
Adolescents and Adults:
* Positiveclient-clinician relationship contributes to successful outcomes
* 60-80% improvement rate, regardless of technique
-Preschool children improve more quickly and easily than school-age, adolescents, or adults
-Intervention across all age groups results in an average improvement for about 70% of cases
~Selecting Intervention method; stuttering~
Depends on:
-Severity
-Motivation
-Specific needs of the client
-SLP’s knowledge of available EBP techniques
-SLP’s skill with EBP techniques
~Indirect Treatment stuttering- preschool age~
Focus on:
Teach parents:
Play-oriented activities that:
No explicit discussion about:
Goal:
Effective for:
If stuttering does not decrease within:
- Focus is on the child, the child’s parents, and the child’s environment
- Teach parents to provide a slow, relaxed speech model
- Play-oriented activities that encourage slow and relaxed speech are a central component
- No explicit discussion about fluent or stuttering speaking behaviors
- Goal is to facilitate fluency through environmental manipulation
- Effective for younger preschool children over a period of 1-2 months
- If stuttering does not decrease within 6 weeks, direct treatment may be recommended
~Direct Treatment, fluency shaping technique~
Prolonged speech: reduce speech rate:
Light articulatory contacts:
Pausing/ phrasing:
Easy Onset:
- Delayed auditory feedback( DAF): A speaker hears their speech after an instrumental delay
- Under DAF, speech is slowed involuntarily
- Slowed speech rate is usually accompanied
by substantial decrease in stuttering - Should be taught to delay each syllable rather than the duration of pauses
- DAF times are adjusted to creates pecific speaking rates, such as 30-60 syllables per minute at the beginning of treatment to 120- 200 syllables per minute at the end of treatment
Light articulatory contacts:
* Reduces speech rate and physical tension before and during occurrences of stuttering
Pausing/phrasing:
* Lengthens naturally occurring pauses and adds pauses
Easy Onset:
* Tension-free onsets of voicing that gradually build in intensity
~Suttering Modification Techniques~
Cancellations:
Pull-outs:
Preparatory sets:
Teaches the person to react calmly to a stuttering event!
Cancellations:
* Complete the stuttered word and pause for at least 3 seconds
* Then produce stuttered word slowly
Pull-outs:
* Modify the stuttered word during the stuttering event
* Slow the sequential movements of the syllable or word
Preparatory sets:
* Prepare to use fluency strategies before attempting the word
* Goal is to initiate the word fluently
Feeding and Swallowing Disorder overview:
Eating is a major social activity
Swallowing disorders increase the risk of choking and may lead to aspiration and pneumonia
Feeding difficulties in children may stress the parent-child relationship
Among older people, dysphagia may lead to isolation, depression, frustration, and diminished quality of life
SLPs are responsible for identifying, evaluating, and treating individuals with feeding and swallowing disorders
SLPs are part of a team consisting of multiple professionals and family members
Phases of Swallowing:
Oral Prep:
Oral:
Pharyngeal:
Esophageal:
Oral Prep: tongue cups to hold bolus, tongue and cheeks move food to teeth for chewing to mix with saliva, bolus is held in mouth by soft palate, palate moves forward and down to touch the back of the tongue and close the passage to the pharynx
Oral: begins once the bolus is formed, bolus is moved from front to back of mouth, pharyngeal swallow reflex is triggered when the bolus reached the anterior facial arch
Pharyngeal: velum contracts so the no bolus in nasal cavity, create pressure, pharynx contracts and squeezes the bolus down, hyoid bone rises and brings the larynx up and forward
Esophageal: muscles of the esophagus move the bolus to the stomach
Dysphagia- Pharyngeal phase
- Incomplete palatal elevation to seal off the nose from the pharynx, allowing foods or liquids into the nasal cavity (i.e., nasal reflux)
- Delayed initiation of the pharyngeal swallow reflex, allowing materials to move deeper into the pharynx or larynx, thus increasing the risk of aspiration
- Diminished tongue and pharyngeal muscle force to move the bolus through the pharynx, resulting in materials “hanging” in the throat
- Reduced laryngeal elevation and closure, making the airway more prone to entering materials (i.e., aspiration)
- Inadequate opening of the cricopharyngeous muscle (i.e.,
the upper esophageal sphincter), hindering the movement of the bolus into the esophagus and enabling the retention of food residuals within the pharynx
Dysphagia- Esophageal
- Referral to a gastroenterologist
- If peristalsis is slow or absent, the complete bolus might not be transported to the stomach
- Residue on the esophageal walls can result in infection and nutritional problems
~Disorder Correlates of Adult Dysphagia~
Stoke:
Head and Neck cancer:
Stoke:
Tongue weakness causes inadequate control of the bolus and difficulty propelling it posteriorly
Swallow initiation may be delayed
Pocketing in the cheek when facial
weakness is present
Sensory deficits and decreased cough reflex can result in silent aspiration
Aspiration pneumonia
-Respiratory infection caused when food or liquid enters the lungs
Head and Neck cancer:
-Swallowing problems are likely after treatments for cancer
-Dysphagia severity related to tumor size/location and surgical procedure
Radiation
Diminished salivation, taste changes, swelling, mouth sores
Chemotherapy
Nausea, vomiting, loss of appetite
~Disorder Correlates of Adult Dysphagia~
Parkinsons:
Als:
Parkinsons:
-Oral transport may be impaired by a front-to-back rolling pattern of the tongue
-Pharyngeal swallow may be delayed
-Laryngeal closure may be impaired
-Aspiration can occur with the patient inhales pharyngeal residue
-Esophageal motor abnormalities impede swallowing
Als:
-Reduced tongue mobility
-Spillage into the airway before the pharyngeal swallow
-Larynx might not elevate and close adequately
-Pharyngeal peristalsis is reduced
- May need to receive most nutrition via percutaneous endoscopic gastrostomy (PEG) tube feedings
~Disorder Correlates of Adult Dysphagia~
Multiple Sclerosis:
HIV/ AIDS:
TBI:
Multiple Sclerosis:
-Delayed swallowing reflex and reduced pharyngeal peristalsis
-Eating difficulties due to hand tremor
HIV/ AIDS:
-Opportunistic infections may affect the oral cavity, oropharynx, and/or esophagus
-Bacterial infections can impair the functioning of cranial nerves for swallowing
-Esophageal ulcers and esophagitis is a major cause of death in individuals with HIV infection
TBI:
-May be unaware of food presented, reduced intake of food or liquid
-May forget to swallow due to distractibility
-Motor deficits are common causes of oral-pharyngeal dysphagia as cranial nerves are often damaged
~Disorder Correlates of Adult Dysphagia~
Dementia:
Medications:
Dementia:
-Cognitive effects of dementia may impede attention and orientation to food
-May forget to eat or may eat the same meal multiple times
- Impaired oral preparatory movements may result in poor bolus formation and drooling
-Transport of the bolus may be prolonged
-Delayed pharyngeal swallow and reduced laryngeal elevation can result in aspiration
Medications:
- May cause drowsiness/confusion, interfering with anticipation and oral phases
- Dry mouth is a common side effect
-High doses of steroids may impede
pharyngeal swallowing
- Prolonged use of antipsychotics may
cause tardive dyskinesia
-Involuntary, repetitive facial, tongue,orlimbmovements
INFANTS AND CHILDREN WITH FEEDING AND SWALLOWING DISORDERS MAY EXPERIENCE:
Malnutrition
Inadequate growth
Dehydration
Ill health
Prolonged feeding times
Fatigue
Difficulty learning
Poor parent-child relationships
~Disorder Correlates of Pediatric dysphagia~
Cerebral Palsy:
ID:
ASD:
Congenital structural abnormalities:
Treacher Collins syndrome:
HIV/AIDS:
22q11.2 deletion syndrome (velocardiofacial syndrome):
Pierre Robin Sequence:
Cerebral Palsy:
-Muscle tone, posture, respiratory
difficulties, high frequency of GERD
ID:
-motor coordination
ASD:
-Sensory hypersensitivity, restrictive food choices
Congenital structural abnormalities:
-Inability to create intraoral pressure, nasopharyngeal regurgitation
Treacher Collins syndrome:
-Anatomical abnormalities of the head & face, compromised airway due to small jaw & retracted tongue
HIV/AIDS:
-Odynophagia (painful swallowing), inability to control oral secretions
22q11.2 deletion syndrome (velocardiofacial syndrome):
- Palatal abnormalities, velopharyngeal insufficiency, nasal regurgitation
Pierre Robin Sequence:
- Micrognathia (underdeveloped jaw), retracted & elevated tongue, cleft palate, obstructed airway
Assessment- Screening Procedures
Infants:
3 oz water test:
Gugging swallow screen:
Infants: failure to thrive
3 oz water test: identifies 80-98% of patients who are aspirating
Gugging swallow screen: can be used with individuals who have had a stroke
* 100% sensitivity, but only 50-69% specificity
Laryngeal Function
Indirect signs:
Other signs:
-Indirect signs are hoarse, gurgly, or breathy voice quality before/during/after swallow
~Other signs~
-inability to rapidly repeat /ha/ with a clear voiced vowel
-Inability to produce changes in pitch, or inappropriate vocal pitch
-Inability to produce a strong cough
-Inability to feel larynx elevate when you place your finger on the thyroid cartilage during the swallow
~Swallow Trials~
-Complete if the client is alert and manages his/her saliva without any signs of aspiration or respiratory compromise
-Food or liquid is usually used
-Some SLPs prefer to use crushed ice or small amounts of water
-If inadequate laryngeal elevation is present along with a strong, productive cough, the exam can proceed
-Client’s reaction to appearance of food and drink is evaluated
-Oral mechanism function is observed throughout
-Inability to cough may suggest difficulty closing the larynx to protect the airway
-Nasal regurgitation reflects inadequate velopharyngeal closure
~Instrumental Dysphagia Evaluation~
Videofluoroscopic swallow study AKA modified barium swallow study (MBS):
Fiberoptic Endoscopic Evaluation of Swallowing AKA FEES:
Videofluoroscopic swallow study AKA modified barium swallow study (MBS):
- X-ray procedure
- Barium is coated onto or mixed into the food or beverage
- SLP determines the size,
texture,consistency of food or beverage and head and body position - Radiologist or X-ray technician uses equipment to observe the movement of barium during the swallow
- Determine whether the client should be fed orally or nonorally, what textures are safest, and the appropriate treatments
Fiberoptic Endoscopic Evaluation of Swallowing AKA FEES:
-Used with pediatric and adult patients who are too ill to go to the radiology dept for MBS
* ENT or trained SLP inserts a flexible fiberoptic laryngoscope through the patient’s nose and into the pharynx
* Patient coughs, holds his/her breath, and swallows foods that have been dyed
* May reveal premature spillage into the pharynx
* Residue may be seen after the swallow
* Can provide information about desirable posture, preferred food types, and aspiration
Compensatory Strategies- Body and Head positioning-
Chin Tuck:
Head-back position:
Head tilt/rotation:
Chin Tuck: For patients with delayed pharyngeal swallow
Head-back position: Recommended for patients with poor tongue mobility if there is excellent airway closure
Head tilt/rotation: Used when an individual has impairment on one side
Direct Therapy- strengthening exercises-
-Swallowing physiology and range of motion may be improved through exercise
-Bite blocks can encourage lowering the mandible
-Flavored gauze or toothettes stimulate tongue/lip movement
-Facilitate awareness of laryngeal movement by placing the hand on the neck at the level of the hyoid bone
-Lip strength and seal may be improved by holding a tongue depressor with the lips
-Push the tongue against a tongue depressor to strengthen the tongue
-Tongue coordination can be improved by moving the tongue in various ways
-Pharyngeal muscle strengthening involves head-lift exercises
Direct therapy- supraglottic and super-supraglottic swallow-
-Supraglottic swallow is used to teach voluntary closure of the glottis and reduces depth of
misdirected swallows
-Breathe in and hold breath
-Put a small amount of food/liquid in the mouth
-Swallow
-Cough or clear throat while exhaling
-Swallow again
-In the super-supraglottic swallow, an effortful breath hold is required
-Supraglottic and super-supraglottic swallow techniques are not recommended for individuals with a history of stroke
Indirect Treatment- Prostheses and Surgical procedures-
-Palatal obturator can help velopharyngeal closure
-Tongue prosthesis might be used for partial or complete glossectomy
-Growths on the cervical spine that displace the rear pharyngeal wall can be reduced
-Dimensions of the vocal folds can be increased and the larynx can be elevated
-Vocal folds can be sutured closed in severe cases of aspiration
-Breathing occurs through a tracheostomy
-Injection of botox is sometimes effective in esophageal dysphagia
Indirect Treatment
Nasogastric tube (NG tube):
Pharyngostomy:
Esophagostomy:
Percutaneous endoscopic gastronomy (PEG):
Nasogastric tube (NG tube):
-Tube is placed through the nose and into the stomach
-Not usually used for more than 5 or 6 months
Pharyngostomy:
-Feeding tube is inserted into a stoma into the pharynx
Esophagostomy:
-Feeding tube is placed in the esophagus through a hole in the upper chest/neck
Percutaneous endoscopic gastronomy (PEG):
-Feeding tube placed in the stomach through a hole in the abdomen
