Exam 3 (SLHS 430)

Basic anatomical structures of larynx (epiglottis, hyoid bone, vocal folds when abducted/adducted, cartilages, and muscles, arytenoid etc.)

Study Photo

Abducted

VF open

Adducted

VF closed

How sound is created: the power source, vibrating source, and resonator

Power source: the lungs/ air

Vibrating source: VF are brought together and airflow is applied to them and they vibrate

Resonator: vibrations from the VF move throughout the vocal tract which changes shape different aspects of sound

Vocal tract

pharynx, oral cavity, nasal cavity

Quality

• hoarseness

• breathiness

• strain/ harshness

• glottal fry

• aphonia

hoarseness

irregular VF vibration, noisy, rough, rapsy, husky

breathiness

air escaping through the vocal folds

strain/ harshness

tension that can be heard when phonation is produced with forcefully adducted vocal folds

glottal fry

cracking or frying sound when a person is phonating near the bottom of their pitch range/ insufficient breath support

aphonia

no voice

Pitch

• abnormally high/low

• falsetto

• diplophonia

• montone

falsetto

un-naturally or artificially high-pitched voice or register, especially for males

diplophonia

audible production of two distinct pitches simultaneously

Resonance

• hypernasality

• hyponasality

• cul-de-sac resonance

hypernasality

excessive nasal resonance; too much air is going through the nasal cavity

hyponasality

lack of nasal resonance when nasal consonants are produced

cul-de-sac resonance

resonance is described as hollow; tongue is in a ball in back of mouth

What causes resonance abnormalities?

dysfunction of velopharyngeal junction

Vocal Nodules

• organic

• benign, callous like

• often bilateral

• soft & pliabile early on, over time before hard & interfere with VF vibration

• occur at the location on the folds where there is the highest impact during phonation

• low pitch, raspy, breathy, loss of vocal range

• often occurs with heavy voice use & frequent misuse

Polyps

• organic

• fluid filled lesion

• result of a blood vessel rupturing then swelling

• typically unilateral

• has its own blood supply

• cause is thought to be phonotraumatic behaviors

• low pitch, rough, breathy, effortful phonation, globus sensation

Sessile Polyps

Raised but flatter bump

Pedunculated Polyps

Stem like, bump hanging off the VF

Reinke’s Edema

• organic

• buildup of fluid in the superficial layer; most severe form the membranous portion becomes permeated with fluid

• result of long-standing trauma or chronic exposure to irritants (smoking)

• swelling can become large enough to cause shortness of breath

• lowered pitch and varying degrees of hoarseness

Laryngeal Web

• organic

• congenital

• normally VF separate by 10th week of gestation

• lack of separation results in webbing: a thin sheet of connective tissue that attaches the two VF

Recurrent Respiratory Papilloma (RRP)

• organic

• one of the most common benign neoplasm of the larynx

• benign wart-like growths often beginning at the anterior portion of the VF and then spreading to the other structures of the larynx

• thought to be caused by HPV

• hoarse, stridor, aphonia, possibly respiratory distress

Neoplasm

abnormal growth of cells

Laryngectomy

• organic

• can be total or partial removal of the larynx

• trachea and esophagus are seperated

• person breathes through stoma in their neck

• loss of VF = loss of voice

• tracheoesophageal voice prosthesis and/or electrolarynx can allow for oral communication despite absence of larynx

Vocal Fold Paralysis

• organic

• recurrent branch of the 10th cranial nerve supply for most of the laryngeal muscles

• damage anywhere along the vagus nerve can cause VF paralysis or paresis

• can be unilateral or bilateral

• paralysis can be in the abducted or adducted position

Organic Voice Disorders Structural vs. Neurological

Structural: the physical structure is impaired

Neurological: something in the neurological path is impaired

Muscle Tension Dysphonia

• functional

• also called hyperfunctional dysphonia

• condition of extra work and strain of the laryngeal muscles

• can occur as a compensatory mechanism for another underlying problem or can be a learned habit

• voice is pressed, strained, may cut out, loss of pitch range, loss of endurance

Aphonia

• functional

• psychogenic voice disorders can result from psychological suppression of emotion

• called conversion disorders because the person is converting emotional conflicts into physical symptoms

• VF are structurally normal and they function normally for nonspeech behaviors

• person may whisper to produce voice

• does not stop until person resolves emotional conflict

• may require some sort of therapy

Who is all apart of the voice assessment team?

• otolaryngologist/ ENT

• SLP

• allergist

• gastroenterologist

• radiologist

Otolaryngologist/ ENT on Voice Assessment Team

Examines ears, nose, sinuses, throat, and vocal mechanism. Provides a diagnosis and prescribes any medications needed to treat the diagnosis, and performs surgery.

SLP on Voice Assessment Team

Examines the functionality of the VF and vocal tract. Provides insight to how the larynx is functioning to produce voice. Designs a treatment plan to include direct therapy and/or behavioral modifications.

Allergist on Voice Assessment Team

Evaluate and treat allergies, asthmas, and immunologic disorders.

Gastroenterologist on Voice Assessment Team

Evaluate and treat digestive orders which may be impacting the voice. (ex. GERD)

Radiologist on Voice Assessment Team

Diagnose abnormalities via CT, MRI, and PET imaging.

Acoustic Assessment

• allows SLP to capture data on irregularities in the vocal signal & compare to norms

• can measure stability of the VF vibration and amount of turbulence or noise in the acoustic signal

Relative Average Perturbation (RAP)

• can get from acoustic assessment

• also known as jitter

• represents the average frequency (pitch fluctuations) from one vibratory cycle to the other

Shimmer

• can get from acoustic assessment

• represents the average amplitude (loudness) fluctuations from one vibratory cycle to the other

Voice Turbulence Index (VTI)

• can get from acoustic assessment

• measure of inharmonic energy (noise) which correlates incomplete glottis closure

Noise to Harmonic Ratio (NHR)

• can get from acoustic assessment

• represents the ratio of spectral noise to harmonic energy

• relative level of noise increases when VF vibration becomes irregular or VF fail to completely close

Aerodynamic Assessment

• measures the airflow and pressure related to speech and phonation

• allows us to understand how the respiratory system is interacting

Visual Assessment

• videostroboscopy

• VF vibrate 80-300 times per SECOND in average adults; this is seen as a blur on traditional endoscopy

• flashing light (called stroboscopy) along with laryngeal microphone allows synchronization to make the vibration appear to be happening in slow motion

• this allows SLPs to view functional abnormalities

Transoral Videostroboscopy

Rigid

Transnasal Videostroboscopy

flexible

Perceptual Assessment

• how does the voice sound?

• subjective measure, but the CAPE-V allows us to make it slightly more standardized

Self-Reported Outcome Tools Assessment

• measures patients perception of the problem

• repeatable for pre- and post- treatment measures

Indirect Intervention for Vocal Abuse & Misuse

Education: help the patient understand what they may be doing to have caused the damage

Vocal Health Strategies

• don’t strain the voice

• hydrate

• don’t smoke

• be cautious of caffeine and alcohol intake

• avoid excess coughing and clearing throat

• prioritize rest

What is physiologic voice therapy?

• strives to balance the three subsystems of voice production

• does not directly work on isolated voice symptoms

• most approaches can be used with a varie

Physiologic Voice Therapy: Vocal Function Exercises

Engages the larynx without any tension, improves physiological frequency range.

Physiologic Voice Therapy: Resonant Voice Therapy

Actively directing airflow up and forward to the nose and face in order to maximize resonance. Allowing more “bang for your buck” and minimizing strain.

Physiologic Voice Therapy: Flow Phonation

Facilitating increased airflow, ease of phonation, and forward focused resonance. Achieving phonation with minimal TVF pressing.

Physiologic Voice Therapy: PhoRTE

Strengthens the respiratory drive and VF closure to combat muscle loss due to aging.

Physiologic Voice Therapy: LSVT or SPEAK OUT!

Intensive exercise treatments developed for patients with Parkinson’s Disease.

Symptomatic Voice Therapy

• focuses on modification of vocal symptoms or perceptual voice components

• addresses voice improvement through direct symptom modification

Symptomatic Voice Therapy: Semi-Occluded Vocal Tract (SOVT) Exercises

Phonating through a narrowing at any point along the vocal tract in order to maximize interaction between vocal fold vibration and the vocal tract.

Symptomatic Voice Therapy: Confidential Voice

Reduce laryngeal tension and hyperfunction and increase airflow.

Symptomatic Voice Therapy: Auditory Masking

Utilizes the lombard effect to have client communicate with a louder volume.

Alaryngeal Speech

A form of communication used by those who get a laryngectomy. It is communication produced without the larynx.

Electrolarynx

A device that can be used to provide an external sound source to create voice. The head of the device is place firmly on the side of the neck, under the chin, or on the cheek. The patient articulates normally. Devices permit for variations in volume and pitch through switch controls.

Tracheoesophageal Voice Prosthesis

Provides an internal sound source for alaryngeal speech. One-way valve crafted from medically high-grade silicone. When inserted, prevents aspiration of food/ liquid and permits pulmonary air to enter the esophagus when the stoma is occluded while the patient exhales. Needs changed every 6 wks-6 mo.

Esophageal Speech

This utilizes the paitients remaining anatomical structures to provide an internal source for sound generation. The patients are trained to place air into the esophagus and then expel the air while vibrating surround tissues. Fluent esophageal speech requires rapid intake and release of air from the esophagus.

What is dementia?

• acquired syndrome consisting of a decline in memory and other related functions

• umbrella term to group all diseases involving memory loss

• symptoms emerge slowly and worsen over time

What causes dementia?

Cortical dementias: Alzheimer’s Disease & Frontotemporal Dementia

Subcortical Dementias: Parkinson’s & Huntington’s Disease

Mixed Dementias: Vascular Dementia & Lewy Body Dementia

What are some dementia symptoms?

• alterations in behavior or personality

• co-occurring movement disorders and sensory disturbances

• memory loss

• difficulty communicating

• inability to learn or remember new information

• difficulty with planning and organizing

• difficulty with coordination and motor functions

• personality changes

• inability to reason

• inappropriate behavior

• paranoia

• agitation

• hallucinations

How can Alzheimers Dementia be managed?

• no medications can cure

• there are recent FDA approved meds to reduce amyloid deposits

• medications to reduce or control cognitive and behavioral symptoms

• monitoring diet and fluid intake to prevent dehydration & malnutrition

• tranquilizers & antidepressants prescribed to control combativeness or aggression to lessen depression

What are characteristics of memory deficits in Alzheimer’s Dementia?

• impaired episodic (recent events)

• impaired working (verbal & visuospatial span tasks)

• semantic memory only in severe pt’s

• procedural memory typically good

• long-term memory remains good in early stages

• phonology & syntax are relatively preserved in early stages

Parkinson’s Disease

• subcortical dementia

• in the later stages, some paitients become demented

• they demonstrate impaired orientation, language, and loss of ability to function in ADL’s

How is cognition and communication impacted in the early stages of Alzheimer’s Dementia?

• difficulty remembering recent events

• phonology, syntax, articulation and voice quality are well preserved

• mild word-retrieval problems and subtle comprehension difficulties may appear

• client can usually recognize difficulties and repair

• functional reading comprehension

• adequate conversationalists: observe conversational conventions such as turn-taking and eye contact

How is cognition and communication impacted in the middle stages of Alzheimer’s Dementia?

• communication impairments become more obvious

• more frequent word-retrieval failures and individuals success in repairing them declines

• sentence fragments and ungrammatical sentences begin to appear

• more passive conversationalists: allow others to pick topic, tone & content

• comprehension of nonliteral material is very impaired

How is cognition and communication impacted in the late stages of Alzheimer’s Dementia?

• can’t read & write

• comprehension of spoken materials is limited to simple & familiar conversation

• speech is primarily single words & sentence fragments which are devoid of meaning & robot like

• syntax breaks down and stereotypic utterances

• neologisms

• unaware of errors

• some pt become mute or echolalic

What are the goals of dementia treatment?

Lessening advancing effects of the disease on the life of the person with dementia and their caregivers/ family members. Minimizing disruptive effects, ensuring safety, and providing support and direction.

What is the SLPs role in dementia treatment?

• assess cognitive communication skills to determine strengths and weaknesses

• maintain and facilitate strengths in their cognition and communication

• educate and help family and caretakers to facilitate communication, be aware of safety issues, and maximize QOL

Candidacy for Dementia Treatment

those who:

• show intent to communicate

• demonstrate cognitive-linguistic strengths around which to structure a treatment program

• respond to cues and stimulation

• follow simple directions

• exhibit recent/ significant change in status

Cognitive Stimulation for Dementia PTs

• picture & object describing

• story recall

• category naming

• problem solving

• word association

Environmental Modifications for Dementia PTs

• schedule of routine activities

• items used in an activity are kept together

• checklist for complex procedures posted where the procedure is to be accomplished

Memory Aids for Dementia PTs

• electronic organizers with built in alarms

• pocket-sized checklists for to-dos

• written cues: notes, labels, lists, signs

• organizational cues: planners, medication boxes

Rationale and how to use memory books/wallets/ and visual reminders 

• PT can captilize on spared recognition/ long-term memory

• may contain personal info such as family members

• may contain ADL’s

• reminder cards to remember appts & who they are

Rationale and goals of Montessori based treatment for dementia 

• uses everyday stimuli and activity to facilitate action, memory and communication

• capitalizes on preserved procedural memory abilities of PWD

• reduces demands on episodic & working memory

• capitalizes on life experience

Global Deterioration Scale (GDS)

1. no cognitive decline

2. age associated memory impairment

3. mild cognitive impairment

4. mild dementia: decreased knowledge of current and recent events, forgetting some of personal history, difficulty managing personal finances

5. moderate dementia: unable to recall familiar address or names of family members, not oriented to time or place

6. moderately severe dementia: forgetting names of very close family members, unaware of year or season, occasionally incontinent, delusional, sleep disturbance

7. loss of ability to speak, walk, and feed self, inconitnent, brain no longer c

Mini Mental State Examination (MMSE)

Quick, 30 min test assessing cognitive impairment. Assesses domains such as orientation, memory, attention, language and visuospatial skills.

What can cause dysphagia & who can it occur to?

• all ages

• various conditions such as CVA, TBI, cancer, tumor, PD, ALS, AD

• symptoms may be acute or worsen over time

• can be sensory, motor, cognitive or a combination

Anatomy and functions of the upper aerodigestive tract 

PICTURE

Aerodigestive Tract

• oral cavity

• nasal cavity

• pharynx

• larynx

• cervical esophagus

Functions of the Aerodigestive Tract

respiration: airway open

phonation: airway open, VF approximated

swallowing: airway closed

Valves in Upper Aerodigestive Tract

1. Lips: closed to keep food in mouth during chewing and swallowing

2. Tongue: makes contact with the roof of the mouth or it can maintain a varying degree of space between itself and the hard palate to manipulate and propel the foods/ liquids

3. Velum: closes during swallow to prevent food from entering nose

4. Larynx: closes during swallow to prevent the entry of food and liquid into the airway

5. Upper Esophageal Sphincter: normally closed except when it opens to allow the food/ liquid to enter the esophagus

Phases of swallow: what happens at each phase and what can go wrong at each phase 

1. oral preparation: forming of bolus

2. oral transport: pushing bolus back

3. pharyngeal phase: bolus in pharynx

4. esophageal phase: bolus in esophagus

Aspiration

food into airway below vocal folds

Penetration

food into airway entrance but not below true vocal folds

Regurgitation/ Backflow

food comes back from esophagus into pharynx or from pharynx into nasal cavity

Residue

food remains in mouth or pharynx after swallow

Clinical Symptoms of Dysphagia

• difficulty manipulating food

• pocketing of food on one side of the mouth

• food or liquid coming out of the nose

• choking on food and medications

• coughing during or right after eating and drinking

• extra effort needed to chew and swallow

• weight loss

Consequences of Dysphagia

• pneumonia

• malnutrition

• dehydration

• death

• social isolation

• reduced QOL

Bedside clinical swallow assessment: purposes, what it looks like, strengths and limitations 

Purpose:

What it looks like: medical history, pt is given liquid and solid trials of different consistencies

Strengths:

Limitations:

Video Fluoroscopic Swallow Study (VFSS)

• modified barium study

• real time x-ray

• movement of bolus can be imaged in real time

• later or anterior-posterior plane

• various foods given to pt during swallow study

• goal is to define PTs swallow disorder

Fiberoptic Endoscopic Evaluation of Swallowing (FEES)

• flexible fiberoptic tube goes through the nose

• difficult to observe oral stages of swallow

• other specialized techniques also used, but not as frequently and not for complete evaluation of swallow

Principles of Dysphagia Management

Eliminate the symptoms of the swallowing disorder without necessarily changing swallowing physiology.