l Voice Disorders
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What to assess?
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1. Resonance 2. Nasal air emission 3. Compensatory articulation patterns -Only about 25% of CL/CP children have speech difficulties after repair 4. Voice
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Why Voice?
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Why voice? Over-compensating by doing things with their voice that's unnatural: glottal stops, straining/pushing to get sound out, hearing loss Might see Hyperfunctional voice disorders, issues with intensity (aren't able to build up subglottal pressure) , monotone voice, tension
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Goals of Assessment
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1. Determine if abnormality exists -Type -Severity -Cause of disorder: Abnormal structure Apraxia Oral motor dysfunction Phonological disorder Developmental delay Normal developmental error 2. Determine need for instrumental testing 3. Determine plan of care
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Timetable of Assessments - First Year
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1. Counseling Diagnosis Effect of anomalies on function Prognosis for the future Verbal communication stimulation 2. Primary concerns of SLP Feeding Prerequisites for speech Monitoring of development
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Timetable of Assessments - Annual screenings and periodic evaluations
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1. Annual screenings until age 4 2. Comprehensive S/L evaluation at age 3 -Resonance and VP function if using connected speech 3. Perceptual assessments -Prior to any surgery designed to improve speech -Document baselines -Postoperative assessment
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Components of a Clinical Assessment OF CLEFT PALATE SPEECH
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1. Diagnostic Interview 2. Oral motor examination -Begins in the waiting room -Similar to Voice OPM *Palpate the palate *Check nasal passages *Note dental anomalies/malocclusions -Cannot make conclusions regarding VP status (cannot see the actual closure part of it ; cant make predictions) 3. Language Screening -Parent questionnaire -Informal *Observation of play behaviors *Spontaneous vocalizations *Repetition of sentences -Formal screening tests of language *REEL: Receptive-Expressive Emergent Language Scale - Bzoch & League, 1991 *ELM: Early Language Milestone Scale - Coplan, 1987
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Speech Samples - Formal
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Formal articulation tests -Can compare to developmental norms -Iowa Pressure Articulation Test/Templin Darley Tests of Articulation (IPAT) *Templin & Darley, 1960 *Sounds in initial, medial and final position *High pressure consonants** -Bzoch Error Pattern Diagnostic Articulation Test by Bzoch, (1979)
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Speech Samples - Informal
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Areas of assessment -High vs. Low pressure consonants (Stops, fricatives, affricates are high pressure consonants) -High vs. low vowels (Vowel Chart) -Oral vs. nasal consonants
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Hiearchy of Tasks
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1. Syllable Repetition 2. Repetition of words containing oral consonants adjacent to nasal consonants 3. Sentence repetition 4. Counting and automatic speech 5. Spontaneous connected speech
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Hierarchy of Tasks 1. Syllable Repetition 2. Repetition of words containing oral consonants adjacent to nasal consonants
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1. Syllable Repetition -Assess for phoneme specific nasal air emission patterns --Test pressure sensitive phonemes with high and low vowels 2. Repetition of words containing oral consonants adjacent to nasal consonants -Examine effect of rapidly alternating VP movement
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Hierarchy of Tasks 3. Sentence repetition
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3. Sentence repetition -Phonemes with similar articulatory placement --Assess phoneme specific errors -Sentences for low pressure --Identify hypernasality --Eliminates consonants that can have audible nasal emission or hyponasality -Sentences with only oral consonants --See nasal emission patterns --Sentences with nasal consonants Identify hyponasality, denasality and culdesac resonance
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Hierarchy of Tasks: 4. Counting and automatic speech 5. Spontaneous connected speech
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4. Counting and automatic speech -Difficult with young children -Sibilants, plosives, high vowels *Build up and continuation of intraoral pressure *Count 60-70 5. Spontaneous connected speech -General speech intelligibility -Influence of context on production of sounds -Consistency of sound production errors
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Evaluate Stimulability
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-Identify sounds that can be readily modified with auditory and visual cues -Identify strategies that facilitate correct production of target sounds: Speech rate Phonetic context Vocal intensity Length of utterance
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Auditory Perceptual Judgement Gold-Standard: Problem:
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Gold standard: Absence of perception in presence of instrumental indicators is not a reason for therapy Problem: experience and reliability -Training and educational materials McWIlliams and Phillips (1990): audio Kuehn, et al. (2002): speech samples Trost-Cardamone (1987): video -Therapist must calibrate their findings with other therapists (inter-rater reliability) within their own patient base (intra-rater reliability)
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Measures of Nasal Air Emission-Visual
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Mirror See-Scape Air Paddle
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Mirror: Hold under... Advantage & Disadvantage....
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-Hold under each nostril during production of speech tasks *Fogging on mirror during production of target oral stimuli Advantage: Simple and inexpensive Disadvantage: Some airflow may be normal
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See-Scape: simple device to detect... Advantages & Disadvantages
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-Simple device to detect air flow/nasal emission (not hypernasality) *Styrofoam float inside a clear vertical tube *Place probe at end of tube inside nostril *Nasal airflow reflected in rising float Advantages: Simple and inexpensive Provides visual feedback to patient Disadvantages: Not reliable enough to quantify severity or progress Can be affected by humidity
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Air Paddle
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Cut piece of paper under the nose
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Measures of Nasal Air Emission-Tactile
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Feel the sides of the nose for vibration
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Measures of Nasal Air Emission-Auditory
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Nose Pinch Stethoscope Listening tube/straw
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Nose pinch
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-Bzoch, 1979 -Produce a speech segment with no nasal consonants with nose unoccluded and then occluded: Normal - No perceptible difference Hypernasal - Sound will resonate in the nasal cavity
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Stethoscope: Listening tube/straw:
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Stethoscope: -Place drum on either side of the nose or under it -Can hear emissions clearly -Must disinfect Listening tube/straw: -Place one end in childs nostril other end near examiner's ear -Don't forget which end went in the nose -Throw out afterwards
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Compensatory Articulations How to Indicate? Description?
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1. How to Indicate -Trost-Cardamone (1997) Diacritic symbols for compensatory articulation 2. Description Glottal stop Pharyngeal fricative Etc...
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Compensatory Articulations Error Analysis & ___, ____, _____
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Error analysis: Phonological processes/identify error patterns: Substitutions and omissions are more common than distortions Pressure consonants are more vulnerable than non-pressure Place errors are more common than manner Place, manner and voicing
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Hypothesize Based on Symptoms:
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1. VPI Hypernasality Nasal emission Compensatory articulation 2. Oral nasal fistula Nasal emission Hypernasality Middorsal palatal stop 3. Abnormal dentition/occlusion Articulatory distortions Oral substitutions 4. Hearing impairment Hyper/hyponasality Voicing Placement errors 5. Mislearning Related to hx of structural abnormalities Unrelated to cleft - Phonological disorder
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Rating Systems: How to rate resonance? Types?
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How to rate resonance: -Normal vs. Abnormal -Hypernasal, hyponasal, mixed -Severity: Mild Moderate Severe -Consistency vs. variability Types: Bzoch McWilliams
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Recommendations for: VPInsufficiency VPIncompetence Velopharyngeal mislearning Symptomatic Fistula
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VPInsufficiency (anatomy): Surgery Prosthesis ; Prosthetics ST for articulation and compensatory productions VPIncompetence (physiology): Surgery Prosthesis ST for articulation and compensatory productions Velopharyngeal mislearning: ST only Symptomatic Fistula: Surgery to close Prosthesis ST for articulation and compensatory productions
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Acoustic Measures - VP function
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Nasometry: -Measures nasal acoustic energy in speech *Oral cavity *Nasal cavity *Calculates ratio of nasal over total: Convert to a percentage = nasalance score High scores compared to normal = hypernasality Low scores compared to normal = hyponasality -Computer based *Visual representation of nasal resonance *Useful for pre and post treatment as well as visual feedback
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Aerodynamic Measures
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Pressure - flow methods: Small catheters in the oral cavity and in the nostril Flow tube into the remaining nostril Estimate presence of VP inadequacy
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Imaging - Nasendoscopy/nasopharyngoscopy:
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Nasendoscopy/nasopharyngoscopy: -Flexible fiberoptic scope inserted through the nostril -Superior view of the VP port at rest and during speech -Permits visualization and evaluation of all VP structures: *Velum *Posterior pharyngeal wall *Lateral pharyngeal walls -Invasive with no radiation -Most common option for visual exam
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Imaging: Multi-view videofluoroscopy
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Frontal: Visualize lateral pharyngeal wall Lateral: Velum and posterior pharyngeal wall Base: Visualize the entire VP sphincter Towne's view: Visualize the VP sphincter Better to use than base when adenoids are enlarged Oblique view: Use if large adenoids or unable to hyperextend the neck
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Goals - Target Behaviors with cleft lip/palate and significant intelligibility problems
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1. Correcting place of articulation 2. Decreasing phoneme specific nasal emission - Directing airflow orally 3. Decreasing perceived hypernasality- Directing airflow orally
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Visual Feedback
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Diagrams Modeling See-scape Mirror Nasometric/Endoscopic feedback
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Auditory Feedback
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Plastic tube from nostril to ear Stethoscope Amplification
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Tactile Feedback
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Toothette Tongue blade Chewing gum
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Therapeutic Techniques
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1. Nose pinch 2. CPAP (597-598) 3. Oral motor exercise 4. Easy (light,quick) articulatory contacts 5. Correcting misarticulations 6. Open mouth posture
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CPAP Oral Motor Exercise
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2. CPAP (597-598) -Continuous positive airway pressure -Provides resistance training -Kuehn (1990's) : Can be used in mild to moderate cases 3. Oral motor exercise -Blowing bubbles through a straw, etc -Controversy
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4. Easy (light,quick) articulatory contacts 5. Correcting misarticulations
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Easy (light,quick) articulatory contacts: Pressure sensitive sounds Prevents build up of air that can produce nasal emissions Correcting misarticulations: Discriminate between the sound and the sensation of the backed and correct placements Teach forward placement using modeling, diagrams and tactile identification of target sites Easy onset -- Glottalization (glottal stop)
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Open mouth posture
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-Increasing proportion of exhaled air through the mouth -May not influence VP closure -Influences other variables that affect perception of hypernasality and nasal emission
