Speech Flashcards
Speech Production
Highly complex motor task that involves approximately
100 orofacial, laryngeal, pharyngeal, and respiratory muscles.
• High speed
• High precision
• Complex coordination and timing of muscle movements
Intelligiblity
- Degree of “understandability” of speech
* Depends on the listener (familiar vs unfamiliar) and context
Fluency
• Rate, rhythm, “smoothness” or flow of speech production (how sounds, syllables, words, and phrases are joined together).
Respiration
Speech production requires airflow from the lungs (respiration) to be ——— through the vocal folds of the larynx and ——– in the vocal cavities shaped by the jaw, soft palate, lips, tongue and other ———, in a ———- (fluency/prosody)
phonated
resonated
articulators
timely and coordinated fashi
• Phonation =
sound waves are created by vibration of the vocal folds.
Airflow from the lungs, as well as laryngeal muscle contraction, causes movement of the
vocal folds.
Pediatric Voice disorders
dysphonias
Common pediatric vocal pathologies
Infectious, anatomic, congenital, inflammatory, neoplastic, neurologic, and iatrogenic causes (McMurray, 2003). • Vocal nodules • Vocal cord cysts • Vocal cord paralysis • Laryngeal webs • Paradoxical vocal fold dysfunction
Vocal nodules
of the most common causes of
pediatric dysphonia
Vocal nodules
Symptoms
- Hoarseness
- Breathiness
- “rough” voice
- “scratchy” voice
- Harshness
- Decreased pitch range
- Throat/ear/neck pain
- Complaint of “losing voice”
Vocal nodules —>
Behavioral voice treatment (voice therapy)
Vocalfoldcysts—->often entails
surgical removal AND possible voice therapy
Laryngeal web—>
surgical resection(may require multiple surgeries)
• Types of articulation errors:
Substitutions
• Omissions
• Distortions
• Obligatory vs active
Phonemes
speech sounds) • Place, manner, voicing • Bilabials, Lingual-alveolars, Velars • Stops, Fricatives, Sibilants, Affricates • Oral vs nasal consonants • Liquids and Glides • Voiced vs voiceless sounds
Treatment of SSD:
SLPs provide treatment to improve
articulation of individual sounds or reduce errors in production of sound patterns.
Treatment of SSD
• Articulation treatment may involve demonstrating how to
produce the sound correctly, learning to recognize which
sounds are correct and incorrect, and practicing sounds in
different words.
Treatment of SSD
• Phonological process treatment may involve
teaching the
rules of speech to individuals to help them say words
correctly.
Treatment of SSD
• More emphasis on
auditory discrimination training (e.g.,
minimal pairs intervention)
Oral-motor therapy is
NOT evidence-based practice
Motor speech disorders (MSD)
Dysarthria (DYS)
• Childhood apraxia of speech
Dysarthria
Collective name for a group of neurologic speech disorders resulting from abnormalities in the strength, speed, range, steadiness, tone, or accuracy of movements required for control of the respiratory, phonatory, resonatory, articulatory, and prosodic aspects of speech production. (Duffy, 2005)
Dysarthria in Children
Congenital:
present from birth (infancy) or prior to the acquisition of speech/language
Dysarthria
• Acquired:
significant variations in presentation depending on age of onset, after the acquisition of at least some speech-language skills
Dysarthria
• Pediatric dysarthria is complex to
diagnose and classify due to the effect of the motor speech disorder on the emerging language and speech processing/production systems
Typical characteristics of dysarthria
Marked difficulties with speech and accuracy of articulatory movements (generalized imprecision)
• Reduced loudness
• Dysphonia
• Hypernasality
• Abnormal speaking rate
• Abnormal breath groups/rate
• Oftenhaveahistoryoffeeding/swallowing problems, drooling, etc.
Dysarthria in Children with Cerebral Palsy
Athetoid (dyskinetic) CP:
slow rate, dysrhythmia, inappropriate voice stoppages & reduced stress, more artic errors
Dysarthria in Children with Cerebral Palsy
• Spastic CP:
breathy voice, monopitch, monoloudness, hypernasality, voice quality changes throughout utterance, better speech intelligibility with fewer artic errors
Dysarthria in Children with Cerebral Palsy
• Speech deficits appear to
involve all speech subsystems (respiration, phonation, VP function, artic)
Dysarthria in Children with Cerebral Palsy
• Decreased
vowel space and reduced word intelligibility
Most children do not present with a
“pure” type of dysarthria
• Mixed dysarthrias
• Dysarthria plus “developmental” phonological disorder/articulation disorder
• Dysarthria plus language disorder
• Dysarthria overlayed on structural anomalies
resulting in a complex mixed speech disorder
! syndromes
Dysarthria and Other MSDs in Down syndrome
• Down syndrome (Trisomy 21) • Childhood apraxia of speech • Dysarthria: reduced speed and ROM, hypotonia, imprecision • Impact of macroglossia vs malocclusion • Speech sound disorders • Voice and resonance disorders; secondary characteristics of VPD • Most often fit a profile of MSD- NOS (Rupela et al., 2016)
Childhood apraxia of speech (CAS) is a
neurological childhood speech sound disorder in which the precision and consistency of movements underlying speech are impaired in the absence of neuromuscular deficits (e.g. abnormal reflexes, abnormal tone).
CAS may occur as a result of
known neurological impairment, in association with complex neurobehavioral disorders of known and unknown origin, or as an idiopathic neurogenic speech sound disorder.
The core impairment in planning and/or programming spatiotemporal parameters of movement sequences results in
errors in speech sound production and prosody (ASHA, 2007).
Treatment approaches for motor speech disorders
Articulation therapy when indicated
• PalatalliftorVPDsurgeryifsignificantly
hypernasal
• Improving “breath support “ and/or loudness (e.g.,
LSVT)
• Augmentative and Alternative Communication (AAC) (e.g., simple gestures, alphabet boards, or electronic or computer-based equipment
• Teaching caregivers, family members, and teachers strategies to better communicate with the person with dysarthria
Resonance:
The perceived
• Velopharyngeal closure
quality of sound, generated from the vocal folds, as it vibrates through the pharyngeal, oral, and nasal cavities.
Resonance
• Balance of oral and nasal sound energy =
Degree of perceived nasality in speech
Resonance
• Influenced by the
size/shape of oral cavity, nasal cavity, pharynx, and surrounding structures (e.g., tonsils/adenoids)
Hypernasality !—>
usually associated with VPI
• PERCEPTION of excessive nasality (too much nasal
resonance) during production of vowels, glides (w, y), and liquids (l, r)
Hyponasality —>
nasal obstruction, midface hypoplasia, septal deviation, choanal atresia, adenoid hypertrophy
• PERCEPTION of denasality/too little nasal resonance during production of vowels and nasal consonants
Submucous cleft palate
- Bifid uvula
- Midline division or diastasis of
musculature of soft palate (zona pellucida) - Notch in the posterior hard palate
Function of the Velopharyngeal (VP) Mechanism
- Alters the general shape and resonant characteristics of the vocal tract
- Connects/disconnects the oral and nasal cavities
* Speech
* Nonspeech
Velopharyngeal Physiology:
•In most normal speakers,
the velum moves up and back, and
the lateral pharyngeal walls move medially
Velopharyngeal Physiology
•VP closure occurs for
swallowing & speech
variation in the degree of closure based on specific demands of speech sounds and coarticulation
• Oral consonants vs nasal consonants
Velopharyngeal Closure
The soft palate stretches
12-25% of it’s length during VP closure
Levator Veli Palatini:
• Originates from
petrous portion of temporal bone and eustacian tube
Levator Veli Palatini
• Descends to insert into
palatal aponeurosis and blends with its paired muscle fibers from the opposite side to form a muscular sling
Levator Veli Palatini
• The most important muscle for providing
adequate velopharyngeal closure for speech
VP Closure:
Inherently disrupted in infants with
cleft palate,due to lack of palatal structures
VP Closure
– After palate repair, structures may be
intact and muscles repaired but function of the VP mechanism may or may not be optimal for speech
VP Closure
• VP closure may be different (is typically “better”) during
swallowing, gagging, etc. than during speech because these behaviors are under separate neurologic control
VP closure
• Never make conclusions about VP closure for
speech based on observations during nonspeech activities
VP Insufficiency
- Short soft palate
- Congenital or following palate repair
- Post-adenoidectomy
- Palatopharyngeal dysproportion (deep retropharynx)
- 22q11.2 deletion syndrome
- Palatal resection due to cancer
- Trauma to the palate
VP Incompetency
Dysarthria – Congenital • Cerebral palsy • Myotonic dystrophy – Acquired • TBI • CVA • Degenerative neuromuscular diseases • Apraxia – Childhood/Developmental – Acquired
Articulation Profiles of
Persons with Cleft Palate/VPD
Reduced variety of speech sounds • Especially infants/toddlers
• Articulation errors
• Speech distortions related to VPD:
• Audible nasal air emission (air escaping through the nose, make sound “turbulent”)
• “Weak” oral pressure consonants
• Hypernasality (Excessive nasality)
Compensatory Articulation Errors
The most common articulation errors of children with cleft palate or VPI:
• Glottal stops:
created by adducting vocal folds abruptly and releasing a “stop-like” consonant at the level of larynx
• nasal fricatives:
substitution of nasal airflow for oral airflow on fricative sounds
Treatment of Resonance Disorders / VPD
Speech therapy is NOT effective
• Typically requires surgical management
• Prosthetics are an option for non-surgical cases
• Importance of accurate diagnosis and appropriate management for best outcomes
• Standard age of treatment of VPD is 4 years of age but if concerns are present, referral should occur at any time
Dental Issues in CLP
May have delayed dental eruption • Missinglateralincisorsincleftsite
• May be missing on noncleft side too
• Malformed/hypoplasticteeth
• Supernumeraryteeth,typicallynearorinsiteofcleft
Orthodontic Issues in CLP
Malocclusioniscommon
• Maxillary transverse collapse and crossbite on the
side of the cleft (“arch collapse”) in CLP • Class III malocclusion common in CLP
• Class II more common in children with CPO
• Patients with CLP tend to have maxillary/midface hypoplasia
Orthodontic issues in CLP
Maxillaryanteriorocclusalradiographsneedtobe obtained
• Mostpatientsneedmaxillaryarchexpansiontocorrect the transverse maxillary relationship prior to alveolar bone grafting
Articulatory distortions related to dental-occlusal hazards
Most commonly affected sounds= – S,Z, then SH, CH, J
• Anterior Crossbiteor Underbite (ClassIIImalocclusion) – Distortions of S, Z, SH, CH, J
– Reversed placement for F, V sounds
• Overjet (ClassIImalocclusion)
– May make P,B,M,likeaForVinstead
• Missing,excessivelyspaced,ormalpositionedteeth(or due to some orthodontic appliances) and openbite
– Distortions of S, Z
Therapy in the presence of
dental-occlusal hazards
• Many children with dental-occlusal problems will still benefit from traditional articulation therapy approaches
• Some children will not be able to eliminate the distortions until the dental-occlusal situation improves
• Alwaysinitiateatrialperiodoftherapyforalltheaffected phonemes before assuming that therapy will not be successful
• Better to target in schoolage children (vs preschoolers)
• Maydefertherapyifdental/orthodontic/surgical
correction of the hazard will occur soon
Orthodontics
- Needed for all patients with clefts through the alveolar ridge, usually when patient is in mixed dentition stage (~age 6-9)
- Braces, headgear, etc.
- Prep for Alveolar bone grafting
• Orthodontia
Alveolar bone grafting
Goal
unite the dental arch, provide sufficient boneto stabilize the alveolar ridge, support dentition, and achieve adequate dental alignment and occlusion
Alveolar bone grafting
• Cancellous cranial or iliac crest bone is grafted into the alveolar area of the cleft site, gives support for arch and eruption of teeth adjacent to the cleft (or support for later pros/implant)
Alveolar bone graft: Timing
• Usually completed around
5-9 years of age (called “secondary grafting”), during mixed dentition, but timing is dependent on dental development
After grafting…
• Reassessocclusion
• Orthodontic tooth movement into the grafted area can
begin approx 3 months after grafting • Realignanteriorteeth
Orthognathic Surgery
• Goal =
treat skeletal malocclusion and reverse overjet and improve facial form and function
Orthognathic surgery;
• Approximately
30%ofCLPpatientsrequire orthognathic surgery
Orthognathic surgery:
• Timing based on
determining when facial growth is complete (approx 15-16 yrs)
Orthognathic Surgery
• Importanceofpre-opspeecheval
- Risk for VPD (or worsening VPD)
* Need for post-op articulation therapy
Prosthodontic Issues in CLP
• Obturation of
fistulae or unrepaired cleft • Speech Prostheses for VPD
Prosthodontic Issues in CLP
• Replacement of
missing teeth
Palatal (fistula) Obturators
Goal =
to provide adequate velopharyngeal closure for speech and swallowing, close off communication/leakage from fistula
Palatal obturators;
• Typically made of an
acrylic or metal palatal plate with retention clasps
Palatal obturators;
• Teeth may be modified to
facilitate retention
Palatal obturators;
• Can add
prosthetic teeth to the applicance
Nasometry
The Nasometer-II is a computer-based acoustic, objective instrument that provides a measurement of oral and nasal sound energy.
• Normative values are available for interpretation in children, adults, and for a variety of dialects and languages based on standard passages and
stimuli.
Nasopharyngoscopy
• Asmallfiberoptic/CHIP TIP nasopharygoscope (attached to a camera and light source) is inserted in the child’s nares and advanced to above the velopharyngeal port
• The velopharyngeal port is observed during specific
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Videofluoroscopy
- Oftencalled“multiviewvideofluoroscopyduring speech”
- Lateral view, frontal view, base view, Towne’s view
- Exposure to radiation, but minimally invasive
- Usually involves administration of barium via the nasal cavity
Role of Speech Therapy
Primarily aimed at correcting articulation errors.
• Does not reduce hypernasality.
• There are no exercises that will “strengthen” the lips/tongue/palate for speech
• Oral-motor therapy is not an evidence-
based practice.
SLPs provide treatment to improve
articulation of individual sounds or reduce errors in production of sound patterns
Articulation treatment may involve
demonstrating how to produce the sound correctly, learning to recognize which sounds are correct and incorrect, and practicing sounds in different words.
These treatment approaches/tools will NOT improve for speech:
horn-therapy program • straw blowing/lip strengthing program • palate massage/stimulation program • yawning/sighing exercises • whistle blowing exercises • tongue movement exercises • “cookbooks” to improve resonance
Surgical Treatment
• Surgery to “correct” VPD, often referred to as
“secondary surgery” or “speech surgery” (~20-30% of pts)
• Usually done at 3 1⁄2 years or later
• Goal: improve velopharyngeal closure for speech
• Most common types: Pharyngeal flap (superior)
• Sphincter pharyngoplasty
• Furlow z-palatoplasty
• Main risk of surgery (flap or sphincter): obstructive sleep
apnea (~5% of cases)
Speech Prostheses
• Prosthodontic approach is a
viable treatment option for selected patients with VPD
• More commonly used in adults with VPD, or cases of neuromuscular origin
Speech Prostheses
• Speech bulb
• Palate too short
Speech Prostheses
• Palatal Lift
• Soft palate of sufficient length but lacks adequate movement
• ! Refer all children with suspected VPD to
Craniofacial (plastic surgery) clinic for evaluation with craniofacial SLP and team
