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89 Cards in this Set
- Front
- Back
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Three types of alaryngeal speech |
1. artificial or electro- larynx 2. Esophageal speech 3. TEP |
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Two types of esophageal speech |
injection: mouth is sealed and air is pushed into esophagus then expelled. inhalation: inhale rapidly while keeping esophagus open and relaxed. |
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TEP (tracheoesophageal puncture) alaryngeal prosthesis |
Shunt connects trachea and esophagus, prosthetic inserted. Patient occludes stoma with finger and exhales, pulmonary air passes through trachea and is diverted to esophagus where it vibrates esophageal tissues |
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Granuloma: overview |
localized, inflammatory, vascular lesion, usually composed of granular tissue in a firm, rounded sac. Caused by intubation injury, vocal abuse, injury, and reflux.
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Associated with contact ulcers |
granulomas |
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Granulomas: symptoms |
breathiness and hoarseness, frequent desire to clear throat |
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Granulomas: treatment |
surgery, voice therapy, or both |
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Leukoplakia: overview |
benign growths of thick, whitish patches on surface of mucosa. D/t tissue irritation (smoking, alcohol, or vocal abuse). Found on anterior 1/3 of VFs. Considered precancerous |
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Leukoplakia: symptoms |
hoarse, low-pitched, breathy, and reduced volume. Maybe diplophonia. |
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Leukoplakia: treatment |
Usually combination of surgery, voice therapy, and eliminating exposure to irritants |
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Subglottal stenosis |
narrowing of subglottal space (acquired or congenital)
Dilation, laser, cricotracheal resection (lower pitch and smaller range, hoarseness, unable to project voice, fatigue) |
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Papilloma: overview |
pink, white or both, wart-like growths caused by HPV. |
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Papilloma: symptoms |
Hoarseness, breathiness, and low pitch. Sometimes airway obstruction |
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Papilloma: treatment |
Voice therapy after surgical treatment. Relaxation exercises, use of amplification devices, training in decreasing supraglottic hyperfunction. |
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Paradoxical VF Motion (PVFM): overview VFD (Vocal Fold Dysfunction) |
inappropriate closure or adduction of the true VFs during inhalation (usually) or exhalation or both. Appears asthmatic. Perception of difficulty breathing and stridor
Presence of SD/MTD?
Youngest is ~7-8, if pt is younger it’s probably not PVCM something else |
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PVFM vs. Asthma |
Stridor on inhalation: PVFM ; Wheeze on exhalation: Asthma
Use of inhalers
How long does attack last
What's onset like? When does it happen?
With asthma, there may be a feeling of tightness or pressure mid chest. With VCD, the tightness is usually felt in the upper chest or throat. VCD and Asthma often occur together, clouding the diagnosis. |
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PVFM treatment: |
endoscopy and feedback, relaxation of vocal mechanism |
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Paralysis and ankylosis: symptoms |
breathiness, reduced pitch and volume, *dysphagia |
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Paralysis and ankylosis: treatment |
acute: injection laryngoplasty - Collagen, gelfoam, fat, cymetra (approx 3mo) chronic: medialization thyroplasty - silicone |
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Spasmodic Dysphonia: overview |
intermittent and involuntary adduction or abduction of VFs during phonation |
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Spasmodic dysphonia: treatment |
CO2 laser surgery, LRN resection, botox, voice therapy
botox: ~ 3mo, 2wk period of breathiness and mild dysphagia. Concurrent voice tx may prolong effect of botox |
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Spasmodic dysphonia: voice therapy |
inhalation phonation, increased pitch, relaxation, head turning, yawn-sigh, easy onset. |
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MS: symptoms |
impaired prosody, pitch, and loudness control, harshness, breathiness, hypernasality, articulation breakdown, and nasal air escape. |
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MS: treatment |
pharmacological |
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Myasthenia Gravis: symptoms |
hypernasal, breathy, hoarse, and soft in volume. *dysphagia and dysarthria, rapid degradation of performance followed by recovery of fx |
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Myasthenia Gravis: treatment |
Corticosteroids |
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ALS: symptoms |
fatigue, breathy, low-pitched, monotonous, poor respiratory control |
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Parkinson's: Symptoms |
breathy, low-pitched, monotonous |
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Parkinson's: treatment |
levodopa, LSVT |
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Treatment considerations for neurological diseases |
-improve articulation through exaggerating consonants and slowing rate of speech -improve resonance -improve prosody - improve respiration -improve VF approximation |
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Nodules: overview |
bilateral, junction of anterior 1/3 and posterior 2/3 |
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Nodules: symptoms |
breathiness and hoarseness |
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Nodules: treatment |
vocal hygiene, good form |
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Polyps: overview |
softer than nodules, fluid filled or vascularized, unilateral. 2 types: sessile and pedunculated |
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Polyps: symptoms |
breathy or hoarse, maybe diplophonia, |
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Polyps: treatment |
vocal rest, voice therapy |
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Contact ulcers: overview |
caused by VFs slamming together, GERD, or intubation |
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Contact ulcers: symptoms |
vocal fatigue and pain, hoarseness and throat clearing. |
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Contact ulcers: treatment |
medical tx, voice therapy |
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Good vocal technique instruction |
- respiration training - pitch and volume regulation - reduce frequency of cough/throat clear - relaxation of body and vocal mech - chant-talk - easy onset - digital manipulation/massage - yawn-sigh - front focused resonance |
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Treatment of loudness |
air pressure/support, reinforce loudness, visual feedback |
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Treatment of Pitch |
relaxation, shaping nonspeech sounds: yawn-sigh or cough speech masking visual/auditory feedback
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Sequelae of HNC |
feeding tube, tracheostomy, |
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4 Crises of HNC |
1. Initial diagnosis - overwhelmed at catastrophe 2. Post surgery - full implications 3. Discharge - leaving safe environment of hosp 4. Post-convalescence - others less attentive/caring |
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HNC: goal of surgery |
remove all harmful tissue + healthy margin Primary closure - stitched Reconstruction - use of tissue from another place on body |
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Radiation Tx |
Applied externally, attacks fast growing cancer cells. Used: before surgery to shrink and make easier to resect, after surgery to kill any leftover cancer cells, in conjunction with chemotherapy |
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Chemotherapy |
Chemical which attacks particular cells, shrink cells or reduce risk of metastasis, increasingly used in conjunction with high doses of radiation (concurrent chemoradiation) |
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Laryngectomy: Post-op considerations |
Make sure pt has appropriate method of communication |
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Focus of alaryngeal speech training: |
articulatory precision: Intelligibility Factors accent, dysarthria, ill-fitting or absent dentition, hearing loss Wet or Gurgling Phonation poor pharyngeal transit, dysphagia, pseudoepiglottis, stricture, etc Hard Attack hyperfunction
rate : Laryngeal speakers 173 wpm Esophageal speakers 127 wpm
attention to nonverbals: Good communication skills eye contact, hand gestures, facial expressions, variations in pitch and loudness, etc Extraneous behaviors behaviors that detract from communication better to address early rather than later
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Electrolarynx: timeline |
Use intra-oral adapter post-op (can be started during hospitalization – do not have to wait for healing to be complete) Neck-type trial after neck edema decreases (usu 1-2 months) Regular follow-up for EL training until independently and functionally communicating |
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EL: cues for listener |
REPEAT what you hear - this provides feedback to the E-L user and this way he/she only repeats what was not understood Establish topic of conversation Establish eye contact Ask for clarification if needed Slower speech rate and exaggerated articulation can improve intelligibility Three Strikes Rule: if spoken message is not understood by the third time, have individual write his/her message - then return to using the E-L |
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Types of TEP |
1. Non-indwelling: easily removed by pt, white flange visible on outside, taped in place. Removed every 3-4 days 2. Indwelling: longer use, replaced by SLP or ENT, 3-6 months of use, |
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TEP initial placement |
Primary TEP Surgeon must clear for TE voicing. Typically 10-14 days post-op Secondary TEP Surgeon and regionally dependant: 24-48 hours after puncture. |
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Additional goals of EL speech: |
Optimal placement of the artificial larynx Neck placement Intra Oral placement Cheek placement
Coordination of “on” control with speaking
Set the up for success when first learning: ask questions with closed set responses or questions you know the answer to |
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Additional goals of TEP: |
Valving: Proper stoma occlusion ◦ Finger Occlusion ◦ HME Optimal pressure Phrasing Normal prosody Coordination of respiration, valving and articulation with meaningful pauses Avoid run-on speech Avoid staccato speech |
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Partial laryngectomy |
Pt must have at least 1 mobile arytenoid Vocal folds removed The cricoid cartilage is sewn up (the “pexy”) to the hyoid, base of tongue (and epiglottis) facilitating airway closure for voicing & swallowing The sound source for voice is the arytenoid cartilage(s) approximating the base of |
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PVFM/VFD: Triggers |
Adults tend to have environmental triggers, while children tend to have exercise triggers. But this isn’t always the case
Exercise Cough Environmental irritants (e.g., smoke, odors, perfume, allergens, change in air temperature) Reflux
Psychological/functional origin |
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PVFM/VFD: Differential tests |
Asthma:
Spirometry: maximal inhalation and exhalation ◦ Flattening of inspiratory loop may indicate upper airway obstruction – will only occur if patient is symptomatic Methacholine challenge Physical assessment |
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PVFM/VFD: Exam |
Have patient vary their breathing for educational purposes (e.g., hold breath, sniff inhalation) and to demonstrate their control of the vocal folds. Challenge patient to exercise or controlled exposure to known irritant in effort to elicit their symptoms Repeat laryngoscopy while they are symptomatic, begin breathing strategies training. If you can’t elicit their symptoms, have the patient imitate them. |
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PFVM/VFD: w/ comorbid asthma - Intervention |
Teaching patients to differentiate between asthma and VCD When to use strategies and when to use inhalers Timing of breathing strategies prior to using inhalers
Medical treatment of VCD involves treating asthma if necessary and discontinuing any unnecessary asthma treatment when there is no asthma, treating any LPR, treating any allergies, referring for counseling if anxiety is a significant component. |
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PVFM/VCD: Treatment |
Preventative Strategies: Methods the patient can use to maintain efficient breathing and prevent VCD attacks, especially during exposure to known triggers Rescue Strategies: Methods the patient can use decrease laryngeal tension and facilitate control of their breathing |
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PVFM/VCD: Preventative Strategies |
Efficient, abdominal breathing throughout the day ◦ Decrease habitual breath holding. Teach continuous breathing without breath holding, especially while concentrating on a task. ◦ Relax the upper body. Help the patient to become aware of and release upper body tension through stretches and correct posture. Efficient voicing – poor vocal technique causes the laryngeal muscles to be tight throughout the day, this increased tension carries over into exercise. Voice training if necessary. ◦ Relaxed, exaggerated breathing as a warm-up in the morning or before exercise. Breathe in through the nose, out through the mouth, alternate nostril breathing. |
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PVFM/VCD: Rescue Strategies |
Rescue Strategies (when not exercising): ◦ Drink water at the first sign of symptoms * |
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PVFM/VCD: Training breathing techniques |
◦ While seated and asymptomatic in the clinic With light exercise – easy walking Gradually increase the exercise intensity: faster walking, easy jogging, running. Negative practice: Have the patient breathe the way they used to, followed by open throat breathing If they become symptomatic during practice, coach them through use of their new strategies. ◦ Practice exercise related to their sport as much as possible ◦ The patient should practice daily while asymptomatic, gradually implement breathing strategies into exercise and their sport ◦ Follow-up visit to evaluate progress and modify strategies as needed. |
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Chronic cough: patient education |
Behavioral strategies to prevent and interrupt cough – control the cough ◦ Usually very successful if the patient is willing to “give up the cough.” Use awareness to interrupt the response to the sensations that have been triggering the cough ◦ “The sensation to cough may be real but.....the need to cough is not” ◦ Review laryngoscopy with patient – help them understand that there is nothing in the airway. |
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Chronic cough: treatment |
First signs of cough: breathing at rest (similar to VCD techniques) * |
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Perspectives on Rehabilitation: symptomatic |
SymptomaticVoiceTherapy: Modificationofthenegative vocal characteristics Assumes that a better voice will be facilitated by changing the vocal characteristics E.g, Use facilitating techniques to raise the pitch, increase or reduce loudness, reduce vocal effort |
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Perspectives on Rehabilitation: Psychogenic |
PsychogenicVoiceTherapy: Basedontheassumptionthat there is an underlying emotional cause for the voice disorder Identify and modify the underlying emotional or psychosocial cause for the voice disorder E.g., stress, tension, depression, conversion disorder Address the relationship of the emotional issues and the voice, tension release, stress management, referral for further counseling |
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PhysiologicVoiceTherapy |
***Yes!
Useofdirectvoicetherapy to alter or modify the physiology of the vocal mechanism Optimal voice is achieved through a balance of respiration, phonation, and resonance. Facilitate this balance through direct exercise and changes in vocal technique Also focuses on maintaining laryngeal health through optimal vocal hygiene |
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EclecticVoiceTherapy |
combinationofanyorallof the other voice therapy methods as appropriate to the patient’s needs |
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Long term goal of voice tx: |
Improve vocal technique to achieve the best possible voice with the least amount of effort (improve vocal physiology) |
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Short term goals of voice tx: |
1. Improve breath support 2. Improve coordination of breath and sound; decrease laryngeal tension during phonation 3. Improve forward vocal resonance or tone placement 4. Improve patient awareness of their voice and vocal technique – including the ability to monitor and correct their vocal technique. 5. Improve vocal hygiene. |
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Isometrics in Voice Tx |
have them tense up and then release to learn the difference
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Different Types of Muscle Tension Dysphonia |
Anterior to posterior muscle squeeze. Usually have decreased resonance and voice fatigue. May or may not have obvious hoarseness. Hard glottal attacks. Difficulty managing airflow often due to frequent breath holding. Sound bursts out of closed vocal folds.
Extrinsic muscle tension with excessive laryngeal elevation (i.e. puberphonia).
Muscle tension in the vocal tract (i.e. throat, tongue, jaw, face muscle tension). |
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Components of Voice Tx: |
1. Vocal Hygiene 2. Vocal Physiology 3. Stress management/awareness as needed |
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Resonant Voice Therapy |
Forward focus with easy voice associated with vibratory sensations in the facial bones. Use of nasally loaded sounds or syllables to achieve this sensation and/or focus RVT: 1x/week for 8 weeks (Verdolini) “basic resonant voice training gesture” Humming and application to functional phrases and ultimately conversation or singing Attention to sensory info and exploration vs analytical explanations about physiology |
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Vocal Function Exercises |
Motor Learning Principles - Specific exercises practiced 2x/day for 8wks - done gently, forward focus, with good posture, minimal effort -Warm up: maximal vowel prolongation -Stretching: glide for low to high -Contracting: glide from high to low -Power: Sustained 5 tones as long as possible, increasing in pitch |
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Vocal function exercises: modifications |
-add abdominal breathing
- find sound that works best for patient
- may only do 3 tones during exercise for non-singers |
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Laryngeal Massage/Digital Manipulation |
Any condition involving muscle tension of intrinsic or extrinsic laryngeal muscles.
-Start with hyoid bone at angle of chin and move to thyroid cart. -Thyrohyoid space starting anteriorly and moving posteriorly in circular pattern -Larynx moved from side-to-side and downward -Voicing can be initiated once you begin to pull downward on larynx -Loosens and lengthens muscles to facilitate relaxation. -Can loosen joints |
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Facilitating Techniques |
-Altering tongue position -Chant talk -Counseling - Digital manipulation -Ear training -Elimination of abuses -feedback -head position -masking -nasal/glide simulation -Easy onset -yawn/sigh -tongue protrusion -respiration facilitation of phonation -chewing -trill/buzz -Altering pitch |
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Lee Silverman Voice Treatment (LSVT): protocol |
-4x/wk for 4wks - Daily hw on tx days - 2x daily hw on non tx days - daily tasks: loud "ah" at max duration Loud glide low to high, hold 5-7 sec Loud glide high to low, hold 5-7 sec Functional phrases -> conversation |
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LSVT: outcomes |
Increased loudness, improved VF closure, louder, stronger voice, improved artic, improved facial expression, increased involvement and confidence |
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How we learn: |
A conversation at the beginning of tx re: how we learn can increase buy-in:
-unconsciously incompetent (or inefficient) -consciously incompetent -consciously competent -unconsciously competent
Repetition and errorless learning |
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Foundations of Vocal Rehabilitation: |
-Coordination of breath and voice -Resonance or voice placement -minimal vocal fold approximation/contact - balancing the voice -achieving the best voice w/ least amount of effort
-Vocal hygiene |
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Tips for SLPs |
Be efficient as possible, move from concepts to conversation as quickly as possible
Help pt understand goals and practice
Problem-solve methods to generalize |
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Who develops nodules (of ped pop)? |
overall behavior consistent with normative expectations
although, significantly higher on social scale |
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Outgrowing nodules |
21% persist, more females than males
2 theories: boys' larynxes change more over time, boys make more abusive noises then grow out of them |
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Pediatric Stimulability Tasks |
Lip/tongue trills humming sustained /hu/ animal sounds voicing through straw noisy bubbles exaggerated nasal sounds sustained phonation with movement sound effects |
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Heirarchy of awareness/self-monitoring |
SLP provides cuing/feedback, client provides feedback with cuing/support, client provides feedback independently, client produces independently without cuing |
