Voice, Adult/Pediatric Dysphagia, Cognitive Communication, TBI, Dementia, Phonological Processes, and RHD

Voice disorders

conditions that affect the quality, pitch, loudness, or flexibility of the voice

Structural, neurological, or functional issues

Communication Disorder

affect a person's ability to receive, send, process, and understand concepts or verbal, nonverbal, and graphic communication.

Granulovacuolar degeneration

Degeneration of nerve cells because of the formation of small fluid-filled cavities containing granular debris

Ecolalia

The non-voluntary, automatic repetition or imitation of another person's spoken words or phrases

Left neglect

a disorder of attention and perception in which a person fails to notice, respond to, or attend to stimuli on their left side

Heterogenous

No two disorders are exactly the same

Confabulation

unintentional creation of false beliefs or inaccurate memories

Neuritic plaque

cortical and subcortical tissue taht is degenerating which DESTROYS NEURAL TRANSMISSION OF MESSAGES

What are the 3 neuropathies that occur with dementia?

1. Neurofibrillary tangles

2. Neuritic plaque

3. Granuloacuolar degeneration

Errorless learning

Ability to go through a task without making any mistakes, we want no struggle, much cueing as necessary to reach 100% accuracy, practice, practice, practice

Space retrieval

like errorless learning, but increasing the time between stimulization of a question and a correct response from the client

Agitation

a state of heightened restlessness, irritability, or emotional distress

Constructional Impairment

neuropsychological disorder where a person has difficulty performing tasks that require organizing or assembling parts into a whole, despite having intact motor strength and coordination.

Narrative

Struggle with story telling, struggle with organization, because of damage to right hemisphere

Limb apraxia

motor planning disorder that affects the ability to perform purposeful movements with the arms or legs, even though muscle strength, coordination, and sensation are intact.

Intracranial hemorrhange

ICH - a type of stroke caused by bleeding directly into the brain

Malnutrition

occurs when the body does not receive the right amount of nutrients

Organic voice disorders

Caused by structural abnormalities

Nodules

Polyps

Cysts

Neurological voice disorders

Result from nerve damage or dysfunction

vocal fold paralysis

Functional voice disorders

No structural damage, but improper use of vocal mechanisms

MTD

Psychogenic voice disorders

Related to emotional or psychological factors

depression

anxiety

conversational aphonia

Epidemiology of voice disorders

Study of voice disorders helps us to treat and identify how the disorder happened

Phonation

Vibrating vocal folds producing acoustic pressure waves, the source of speech

Pitch

Perceptual measure of vocal fold vibrations per second

high vs. low

Frequency

Physical measurement of pitch, measured in Hz

high vs. low

Loudness

Perceptual measure of volume of sound pressure level

loud vs. soft

Intensity

Physical measurement of loudness, measured in dB

loud vs. soft

Distance between speaker and listener

Quality

A mix of tonal and atonal in the acoustic pressure wave produced by the vocal fold and sound pressure level

Variable based on speaker and culture

EX: Arabic speakers

Tonal

Pitch, resonance, and vocal quality

piano keys

Anosagnosia

Lack of awareness or insight into their own deficits

Atonal

Noise such as humming from an AC unit

Intubation

a tube is inserted into the trachea through the mouth or nose to maintain an open airway or to administer medical treatments

Dysphonia

Voice disorder, either perceived by others or by oneself

Aphonia

No voice

__ of people have reported a voice disorder at some point in past 12 months

6%

Voice disorders are more prevalent in...

1. Ppl with fam history

2. Women

3. Professional voice users

Why are women more prevalent in voice disoders?

1. Talk more

2. High pitch

3. Frequent pitch changes

4. Hormones

List professional voice users

1. Singers

2. Teachers

3. Athletes

Diagnosis of voice disorders

1. Physician evaluation

2. case history

3. Perceptual impressions of own voice

4. Viewing imaging of vocal folds

5. Measurement of phonatory parameters (F0, intensity, frequency, voice spectrum)

Why does there need to be a physician evaluation before SLPs work with voice disorders?

1. We must know the cause of the disorder in order to have a detailed treatment plan

2. If surgical intervention is needed, that must happen first

Fundamental frequency

1. Highest in kids

2. Related to the size of the larynx

3. Declines in childhood to puberty

4. The adult average is constant in males and females

5. Higher = higher pitch

Hypofunction voice disorder

breathy voice, vocal fold cycles are too slow to close

Hyperfunction voice disorder

Rough, tense voice, vocal fold cycles close too fast

Phonotrauma

Dysphonia due to excessive phonatory behaviors, resulting in damage to the vocal folds

Excessive phonatory behaviors

1. Chronic screaming

2. Overuse of high intensity

3. chronic throat clearing

4. chronic low-pitched

5. tense voice

Healthy vocal folds

Vocal fold nodules

Benign masses resulting from chronic overuse

Begin soft, then turn callous texture

Occur bilaterally

Voice quality is breathy

Vocal fold polyps

Softer than nodules, unilateral, can develop from a single scream

Laryngitis

Disturbs free motion of outer layers of vocal fold tissue, swelling

Chronic reflux

Acid on vocal folds, tobacco, alcohol

Vocal fold cysts

Fluid filled sac interfere with free motion of outer layer of vocal folds

Treatment of phonotrauma

For all, educate on vocal hygiene

Treatment of nodules

Vocal rest, may need surgery if unsuccessful

Treatment of polyps or cysts

Surgical removal, scar tissue can also become an issue after suergy

Acalculia

Loss of ability to perform simple arithmetic calculations, typically resulting from disease or injury to the parietal lobe of the brain.

treatment of laryngitis and reflux

Vocal hygiene for dysphonic episodes

Avoid straining voice

Teach them to use breath to increase volume

Arousal

​​ The brain's ability to be awake, alert, and responsive to stimulation.

Lability

rapid shift of emotions

Manic

having the quality of excessive excitement, energy, and elation or irritability

MTD

Functional voice disorder (muscular tension dysphonia), excessive tension in the head and neck, is a functional voice disorder

Can occur at any age

60% women

Strained vocal quality

Aphonia

If diagnosed with MTD

1. Counseling for psychological issues

2. Direct voice therapy to reduce tension

3. Laryngeal massage

Unilateral vocal fold paralysis

Functional voice disorder that has injury to the nerve on one side of the larynx bc of trauma, injury of the nerve in surgery, or inflammatory disease

Breathy, strained, weak voice quality

Treatment for Unilateral vocal fold paralysis

Direct voice treatment or surgical intervention

1. Speech breathing with controlled effort exercises

2. Surgery: injecting biomaterials to plump folds to meet at midline or moving the fold into a permanent position at midline

Spasmodic dysphonia

Neurological voice disorder that is rare, intermittent, and irregular voice spasms, where phonation can be nonexistent or have tremors of the folds

Treatment for spasmodic dysphonia

1. Botox injections to reduce spasms

2. Counsel client to live with condition

Cancer of the larynx

Occurs anywhere in the larynx, more in men, changes in voice increase in severity over time, hoarse, rough, irregular voice quality

Treatment for cancer of the larynx

1. Surgery and radiation

2. Voice therapy

Pediatric voice disorders

1. 4-6% of kids

2. More common in boys under 12

3. Behavioral voice therapy for benign conditions

4. Educate on vocal hygiene

Compensatory strategies

Help the person eat what they can right now, but do not strengthen the swallowing system

Dysphagia

Inability to manage and swallow food/liquid appropriately

Observed by patient symptoms

1. Issues putting food in mouth

2. Coughing before, after or at the end of a meal

3. pneumonia

4. wet/gurgly voice

5. Feeling of food stuck

6. food refusal

7. Weight loss

8. Dehydration

9. Malnutrition

Dehydration

Lack of hydration/lubrication in vocal folds can cause voice disorder

Primary symptoms of dysphagia

Aspiration, penetration, residue, backflow

Aspiration

Food/liquid past the vocal folds into the vocal tract

epiglottis stops working, causing pneumonia

Penetration

food/liquid stuck in the laryngeal vestibule, does not drop below the folds

Residue

Any food/liquid that stays where it should not be after a swallow

Backflow

reflux from the stomach to the esophagus or into the larynx

Bolus

Food/liquid we are swallowing

Bolus feed

food/liquid that is inserted through a peg tube

Swallowing

Patterned response, reflexive, complex

Swallowing sequence

1. Medulla recognizes pattern of sensory and motor elements triggering swallow

2. Feedback from tongue helps trigger swallow

3. Input from both cerebral cortex and cerebellum responsible for coordination and timing of motor movements

Cranial nerves involved in swallowing

1. V Trigeminal

2. VII Facial

3. IX Glossopharyngeal

4. X Vagus

5. XI Accessory

6. XII Hypoglossal

V Trigeminal Nerve

Sensory - jaw, teeth, lips, cheeks, tongue, hard palate

Motor - chewing

VII Facial Nerve

Sensory - soft palate, taste anterior 2/3 tongue

Motor - superficial muscles of face, stylohyoid

IX Glossopharyngeal Nerve

Sensory - tonsils, pharynx, soft palate, taste, tactile posterior 1/3 tongue

Motor - pharyngeal elevators

Salvation and gag reflex

X Vagus Nerve

Sensory - larynx, pharynx, trachea, esophagus

Motor - intrinsic muscles of larynx, palatal muscles, pharynx

Swallowing

Runs all the way to stomach

XI Accessory Nerve

Motor - pharynx, extrinsic larynx, uvula

Swallowing

XII Hypoglossal Nerve

Motor - strap muscles of neck, extrinsic and intrinsic tongue muscles

Tongue movement

Neurogenic conditions

1. Stroke

2. Operable brin tumor

3. TBI

4. Dementia

5. Neurodegenerative disorders

6. Non-operable brain tumors

Stages of swallowing

1. Oral

2. Pharyngeal

3. Esophageal

Oral preparatory stage of swallowing

You have the food in your mouth, preparing to move food into the pharynx

Voluntarily eating

Rotary mastication

Teeth bite and chew

Mandible moves circular and opens

Saliva increases

Bolus formation via tongue movement

Velum drops down

Lips closed

Cheeks keep food in center of mouth

Duration varies based on what you eat

Positive pressure

Force from muscles compressing/pushing the bolus forward through the oral and pharyngeal cavities

Negative pressure

Region of lower pressure that helps draw the bolus forward

Structural Conditions

1. Head and neck cancer - stops and blocks food

2. Cricopharyngeal hypertrophy - overgrowth of muscle

3. Zenker's diverticulum - food stuck in pouch

4. Cervical neck disease - boney growths

Iatrogenic Conditions

Caused by the treatment

Tracheostomy

Ventilators

Drugs causing dry mouth, decreased sensation, taste, oral moisture

Post surgical nerve damage

Psychiatric/Behavioral Conditions

Globus pharynges - feeling like lump in throat

Delirium - physical or mental illness (UTIs or mania)

Alcohol

Systemic Conditions

Myositis - autoimmune disease-causing muscle inflammation

HIV/AIDS - mouth, throat, tongue sores or yeast infections of the mouth

Esophageal causes - GERD

Oral transit stage of swallowing

When the food leaves the mouth, tongue pushes up on hard palate to send food back and down the pharynx

Voluntary

Jaw and lips closed

tongue tip strips back on alveolar ridge

Breathing in and out

Peristaltic tongue motion

Bolus reaches anterior faucial pillar

Bolus enters pharynx

Pharyngeal stage of swallowing

Swallow is triggered

Pharyngeal stage of swallowing pharynx components

Moves bolus to upper esophageal sphincter

1. Velum elevates to block off nose

2. Pharyngeal walls squeeze in

3. Bolus pulled by negative pressure

4. Tongue pushes bolus to propel into pharynx, base of tongue is down

5. Muscles contract in wave from top to bottom naso-hypo pharynx

6. Ends when upper esophageal sphincter is in esophagus