Communicative Disorders: Final Exam

Dysphagia

• Impaired swallowing; a disorder of swallowing food and liquid

• Also known as deglutition disorders

• Consists of 4 phases:

  • Oral preparatory phase of the swallow

  • Oral phase of the swallow

  • Pharyngeal phase of the swallow

  • Esophageal phase of the swallow

Oral preparatory phase of the swallow

• Preparing for the food to enter the mouth, placed into the mouth, and helping to prepare for the eventual swallow

• Beginning of bolus formation takes place here

  • Bolus - portion of food chewed and mixed with saliva, prepared into a ball, and is eventually swallowed

• Problems here involve: problems chewing food and forming a bolus due to reduced tongue and lip function and aspiration of food or liquid into the airway before the swallow has occurred

Oral phase of the swallow

• Involves movement of the bolus from the front to the back of the mouth and ends when the swallow reflex is initiated

• Problems here involve: continued tongue weakness, reduced range of motion to propel bolus back to be swallowed, food residue left in the mouth as the swallow is attempting to take place, and delayed onset of the swallow

Pharyngeal phase of the swallow

• The swallow takes place; the larynx elevates, the soft palate elevates to close off the nasopharynx preventing food or liquid from entering the nasal cavity, and the epiglottis flips down to cover the airway preventing food or liquid from entering the trachea/airway to lungs

• Once this takes place, the pharynx contracts and squeezes the food or liquid through the esophagus to the stomach

• Problems here involve: difficulties propelling the bolus through the pharynx into the esophagus and inadequate closure of the airway resulting in aspiration before or after the swallow

Esophageal phase of the swallow

• This occurs when food travels through the esophagus to stomach

• The upper esophageal sphincter opens at the top of the esophagus from the pharynx to allow the food or liquid bolus to enter, then the lower esophageal sphincter opens to allow food or liquid to leave the esophagus and enter the stomach

• Problems here involve: difficulty passing the bolus through these sphincters and reflux of the food or liquid passing back up through the esophagus or pharynx due to the sphincters not opening properly

Most common causes of dysphagia include:

• CVA (strokes)

• TBI (traumatic brain injury)

• Dementia

• Cerebral palsy

• Parkinson’s disease

• Other neurological disorders (varieties)

• Surgical problems related to the laryngeal area

• Laryngeal cancer

• COPD (chronic obstructive pulmonary disease)

• Side effects of certain drugs

• Myasthenia gravis

• Multiple sclerosis

Assessment involves:

• Bedside dysphagia evaluation involving oral motor exam, case history interview to determine current diet and problems noted with certain foods and liquids, assessment for tolerance of ice chips, water, pudding/applesauce. and crackers

• MBS (modified barium swallow or rehab barium swallow) - also known as a video-fluoroscopic swallow study is an X-ray procedure that evaluates how the structures in your neck and mouth work when you swallow, drink, and chew; it is also used to determine if you’re aspirating, which is where food or liquid enters your lungs

• FEES (fiberoptic endoscopy of the swallow mechanism) - a portable procedure that assesses how someone swallows; it uses a flexible tube with a camera and light on the end of the tube to examine the throat and upper aerodigestive tract; can also determine aspiration

• Management involves: vital stimulation strengthening, oral motor strengthening, diet management, oral intake and diet training with the family and patient, head and tongue positioning during swallowing, swallow maneuvers, vocal fold adduction strengthening exercises, respiratory sufficiency and cough strengthening exercises, laryngeal elevation strengthening exercises and diet upgrades as safely tolerated

  • Also if the patient has a feeding tube, then feeding tube weaning to an oral diet will be properly trained with the patient and family

Cerebral palsy

• Disorder of early childhood in which the immature nervous system is affected

• Results in muscular incoordination and associated problems affecting both speech and swallowing in relation to our field of study

• Speech therapy focuses on improving swallow function and speech/respiratory problems related to this disorder

  • These patients typically have oral-pharyngeal dysphagia/swallowing problems and very disturbed slurred, spastic speech, and respiratory issues that affect speech production all of which require speech therapy

Ataxic cerebral palsy

Involves disturbed balances, awkward gait, and uncoordinated movements due to cerebellar damage

Athetoid cerebral palsy

Characterized by slow, writhing, involuntary movements due to damage to the indirect motor pathways and basal ganglia damage

Spastic cerebral palsy

Involves increased spasticity (increased tone, rigidity of the muscles, stiff, jerky, abrupt, slow movements) all due to damage to the motor cortex of the brain

Autism

• A behavioral disorder characterized by impaired social interaction, including deficient verbal and nonverbal communication and repetitive and stereotypic behaviors, interests, and activities

• Assessment and treatment would target areas of concern as noted above in addition to any speech/articulation and swallowing difficulties that may be occurring

Characteristics of autism:

• Lack of interest in nonverbal and verbal communication

• Stereotypic body movements, such as rocking

• Insistence on routines

• Dislike of being touched or held

• Self-injurious behaviors

• Unusual talent in some areas such as math or numbers

• Hyper or hypo-sensitivity to sensory stimulation

• Inadequate or lack of response to speech

• Deficits in comprehension and use of figurative language

• Perseveration on certain words

• Echolalia

• Use of short, simple utterances, use of incorrect word order, and omission of grammatical features

• Lack of eye contact, difficulty maintaining conversational topics, reduced initiation of conversation, and lack of inflection and intonation patters during utterances

Augmentative and alternative communication

• A multimodal intervention approach that uses forms of communication, such as picture communication boards, manual sign language, and computerized or electronic devices that produce speech (speech-generating devices)

• Populations that may benefit from AAC devices include:

  • Cerebral palsy

  • Multiple sclerosis

  • Dysarthria patients

  • TBI patients (traumatic brain injury)

  • Stroke patients

  • Autistic patients

  • ALS (amyotrophic lateral sclerosis)

  • Down’s syndrome

  • Developmental language delays

  • Apraxia

Literacy and speech/language development:

• Skills that preceded conventional reading and writing; include such preschoolers’ skills as letter recognition and sight-reading words; reading and writing skills

• The clinician/SLP should work with the family members to educate them about the importance of a literacy-rich environment (reading to your children, exposing them to books, writing, and drawing)

• Beginning to read to your children from an infant on builds interaction skills, oral awareness, auditory and receptive awareness and eventual verbal productions stemming from increased vocabulary that has been introduce

• Parents should be the role models

• Vocabulary skills will increase reading comprehension and fluency and build oral language as well

Research consistently supports the efficacy of targeting phonological awareness skills including:

• Rhyming - correct identification of words that sound alike (hat-cat)

• Syllable awareness - encouraging with the child how many syllables are in a word and sounding them out

• Phoneme isolation - identifying whether the sound is at the beginning, middle, or end of a word; also sounding out specific sounds for production and awareness

• Sound blending - blending 2 or more sounds that are temporarily separated by a few seconds into a word (d — o — g; what animal is that?)

Anatomy of the ear consists of the:

outer, middle, and inner ear

Outer ear contains the:

auricle (pinna) and the external ear canal

Middle ear contains the:

ossicular chain (malleus, incus, and stapes), the eustachian tube, and the eardrum

Inner ear contains the:

oval window, round window, semicircular canals, and the cochlea

Landmarks of auditory recognition:

• Birth to 3 months

  • Startle reflex should be noted; quiets or smiles when spoken to

• 4-6 months

  • Moves eyes in direction to sounds; responds to changes in tone of voice; pays attention to music

• 7-12 months

  • Enjoys games like peek-a-boo and pat-a-cake; begins to respond to requests like “come here”

• 1-2 years

  • Points to a few body parts when asked; follows simple commands; listens to simple stories, songs, and rhymes

• 2-3 years

  • Understands the differences in meanings of words; follows 2 step requests

• 3-4 years

  • Hears when you call them from another room; understands simple “wh” questions

• 4-5 years

  • Pays attention to a short story and answers simple questions about it’ hears and understands most of what is said at home and in school

Conductive hearing loss

• Occurs when sound is prevented due to problems through the ear canal and middle ear; may be caused by wax impaction, middle ear fluid/otitis media in the middle ear, or abnormal fusion of middle ear bones

• Middle ear hearing loss

Sensorineural hearing loss

• Occurs when damage to the cochlea or auditory pathways that deliver information to the cochlea occurs

• Inner ear hearing loss

Mixed hearing loss

• A combination or both conductive and sensorineural hearing loss

Hearing losses may be:

• Congenital (born with)

• Acquired (developed after birth due to a condition, disorder, or injury)

• Idiopathic (one of unknown cause)

Common signs of hearing loss:

• No response when called

• Inconsistent response to sound

• Delayed speech and language development

• Unclear speech production as the child grows and develops; problems with articulation, language, fluency, voice, and resonance

• Inability to follow directions

• Frequent requests for clarification (saying huh or what)

• Sound turned up on TV or electronic equipment

Assessment of hearing loss:

• Audiological assessment always performed on newborns to rule out any possible hearing loss

• Case history interview of family and determine if history of hearing loss in the family

• Tympanometry - equipment that assesses eardrum or middle ear function/abnormalities

• Auditory brainstem response - technique that is used to record the electrical activity in the auditory nerve, brainstem, and cortical areas of the brain

• Direct observation of the infant or child through informal play

Amplification of hearing loss:

• Body aid - worn under the person’s shirt

• Behind the ear - fits behind the ear

• In the ear - a small unit which fits within the concha of the external ear

• In the canal - fits in the ear canal and is less visible

• Cochlear implant - for those with a profound hearing loss and cannot benefit from aids; electronic devices surgically placed in the cochlea and other parts of the ear which deliver sound directly to the acoustic nerve endings in the cochlea

Speech therapy needs for the hearing impaired:

• Counseling with the patient and family re: the hearing aid and it’s use

• Aural rehabilitation

  • An educational and clinical program generally implemented by the audiologist and speech pathologist to help those with hearing loss achieve their full potential in communcation

  • Focuses on articulation, speech, and language testing and once weakened areas are identified, those certain areas are treated and targeted during therapy