speech disorders final exam: Detail View

1)

2 possibilities for differential diagnosis in adults who stutter

1. adult onset of stuttering2. cluttering

2)

2 possibilities for differential diagnosis in adults who stutter

1. adult onset of stuttering2. cluttering

3)

Disorder of speech AND language processing that results in rapid, disorganized, dysrrhymthic and frequently unintelligible speechseveral defintions exist

4)

4 major types of adult-onset stuttering

1. recurrent- stuttered in childhood2. psychogenic- caused by psych. event (rare)3. neurogenic- occurs after neuro. damage4. pharmacological- side effect of drugs (antidepressants)

5)

How is cluttering different from stuttering

In cluttering, there are language deficits, rapid speech & disorganization not seen in stuttering; may have attention deficits; often coexists with phonol. errors, learning & lang. impairments, attention deficits & stuttering

6)

How could you test to see if a client is cluttering versus stuttering

Do a lang. assessment & test intelligibility (cluttering more unintelligible)

7)

Characteristics of cluttering

Rapid, variable or accelerating speech (jerky)disfluencies: vowel-initial pauses, effortless multiple repetitionsartic. and prosodic errorsfew or no accessory behaviors and little or no struggle speaking

8)

Characteristics of cluttering

Rapid, variable or accelerating speech (jerky)disfluencies: vowel-initial pauses, effortless multiple repetitionsartic. and prosodic errorsfew or no accessory behaviors and little or no struggle speaking

9)

Cognitive and lang. characteristics of cluttering

Attention deficitsreading & writing problems

10)

Other characteristics of cluttering

Don't realize they are unintelligibleslips of tongue"soft" signs (might be clumsy or uncoordinated)maybe positive family history of cluttering or stuttering

11)

Steps for Ax of cluttering

Interview client & significant othersassess rate and disfluenciesscreen for co-existing oral, motor, lang., pronunciation, learning, attention, or social problemsobtain idea of child's academic achievement (IQ)assess if it co-occurs with stuttering

12)

Treatment of cluttering

Address problems with lang., attention, stutteringreduce speaking rate (time speech, DAF)pause deliberatelysame techniques at Tx of stuttering (easy onset, etc.)may work on prosody (include all syllables in speech)teach self-monitoring through videotaping

13)

How many workers in the US have daily voice problems?

28 million

14)

What is the prevalence of voice disorders?

6-10% in kids and adults

15)

Most common etiology of voice disorders

Vocal nodules

16)

What info does voice tell us about a person?

Age, gender, emotion, health, etc.each person has a unique voice ("voice printing")

17)

Functions of larynx

1. voice production2. protects airway (most important!)3. larynx shuts to bring subglottal pressure when lifting heavy objects or in childbirth4. helps with defecation

18)

What bone holds up the larynx?

Hyoid bone

19)

Shield-like cartilage of larynx

Thyroid

20)

Ring-like cartilage of larynx

Cricoid

21)

Vocal and muscular processes are located on which cartilage of the larynx?

Arytenoid

22)

Rocking and gliding movements of vocal and muscular processes allow VF's to ___ and ___

Open (abduct) & close (adduct)

23)

Which joint does the rocking and gliding movements to open/close vocal folds?

Cricoarytenoid joint

24)

What closes over the larynx to prevent food & water from getting into the airway during swallowing?

Epiglottis

25)

Vocal fold abductor muscle

Posterior cricoarytenoid

26)

Vocal fold adductor muscles

Lateral cricoarytenoids, interarytenoids, thyromuscularis

27)

Function of cricothyroid muscle?

Controls pitch; lengthens VF's

28)

Vocal folds are joined at the ___ end

What is the space between the vocal folds

Glottis

30)

Which muscle makes up the main mass of the vocal folds

Internal thyroarytenoid

31)

Extrinsic vs. intrinsic muscles of larynx

Extrinsic- 1 attachment located outside larynxintrinsic- all attachments located within larynx

32)

Thyroarytenoids

Vocalis & muscularis partslowers pitch by reducing tension of VF's

33)

Function of infrahyoid muscles

Pull the larynx down

34)

Function of suprahyoid muscles

Pull larynx upimportant for swallowing

35)

2 different folds of larynx

Ventricular (false) foldsvocal (true) folds

36)

Multilayering of the vocal folds results in a ___ ___ wave

Complex sound

37)

3 branches of Vagus nerve

Pharyngeal, recurrent laryngeal, superior laryngeal

38)

The pharyngeal branch of the vagus nerve supplies muscles of the ___ ___

Soft palate

39)

The superior laryngeal branch of the vagus nerve supplies what muscle?

Cricothyroidalso gives sensation to larynx

40)

The recurrent laryngeal branch of the vagus nerve supplies ___ other laryngeal muscles

All

41)

Average pitch for males and females?

Males- 110 Hzfemales- 225 Hz

42)

When you want to lower pitch to extreme levels, the larynx is ___

Lowered

43)

What are the five layers of the vocal folds?

Epitheliumlamina propriasuperficialintermediatedeep

44)

Why is layering of the vocal folds important?

They allow for tissue rebound (complex waves)

45)

Function of the ventricular folds

None- they only vibrate in a disorder

46)

What is the primary nerve of the larynx

Vagus (CN X)

47)

Medial compression

Squeezing false supraglottal structures to obscure laryngeal inlet & vocal foldsresists air lung pressure

48)

Longitudinal tension

Tension of vocal foldspitch control

49)

Subglottal pressure

Pressure below the glottisregulates intensity of voice

50)

Fundamental frequency

Average number of glottal cycles per second --> perceived as pitch

51)

Muscles involved in changing pitch

Cricothyroidinternal and external thyroarytenoids

52)

How do you change the pitch of your voice?

By either stiffening or elongating the vocal folds

53)

How do you increase vocal intensity

Increase air pressure, volume of air, and bernoulii effectalso increase medial compression by adducting VF's

54)

How is phonation a myoelastic-aerodynamic phenomenon?

Glottal vibration is due to aerodynamic (subglottal pressure & bernoulli effect) & myoelastic/muscular (tissue elasticity) forces

55)

Dysphonia vs. aphonia

Dysphonia= disordered voiceaphonia= loss of voice

56)

2 realms for describing voice

1. perceptual- sounds hoarse, strained, etc.2. acoustic- pitch, intensity, etc.

57)

In which stage of life do you have the highest pitch voice?

Infancy

58)

During childhood, your pitch ___

Lowers

59)

In which stage of life is there the biggest change in pitch?

Puberty, esp. in males

60)

Adult voice from ages __ to __ stays about the same

18 to 60

61)

What happens to your voice & pitch when you are above age 60?

Voice starts quivering (less muscle control)pitch slightly increases for males and slightly decreases for females

62)

___ condition is very important for voice

Physical

63)

4 classifications of voice disorders

1. vocal abuse/misuse or phonotrauma (functional)2. neurogenic (neurological diseases)3. structurally related (organic)4. psychogenic/stress (from trauma, functional)

64)

Possible causes for vocal abuse/phonotrauma

Yelling, excessive talking, smoking, drinking, constantly clearing throat or coughing, kids crying excessively, boys making play noises, talking over noise, illnesses (allergies or URTI)

65)

People most likely to be affected by vocal abuse

Teachers, women, between 40-59 years of age, family history of voice disorders

66)

Vocal nodules are most common in which population?

Children

67)

How does a person's voice who has vocal nodules sound?

Breathy, hoarse, rough, voice breaks

68)

3 different consequences of vocal abuse

1. vocal nodules2. vocal polyps3. contact ulcers

69)

Vocal nodules

AKA singer's nodulesfirst soft then fibrous/callous growth on VF'susually bilateralhigh chance of recurrencemay resolve with puberty

70)

Treatment for vocal nodules

Voice therapy- behavioral management (diet)

71)

Vocal polyps

Flat, fluid-filled bumps on VF's (like blisters)usually unilateralcan result from single bad episode of abusesymptoms similar to nodules

72)

Treatment for vocal polyps

Early on use voice therapy but if chronic may do surgery to remove polyps (can interfere with breathing)

73)

What population do contact ulcers affect most?

Affects middle-aged males esp. those who speak with a vocal fry(lowest pitch) or excessive force (glottal attacks)

74)

What are contact ulcers

Affect mucosa covering vocal processesmay get covered by granulation tissuemajor symptom is pain which radiates to ear (earcache)associated with reflux

75)

Treatment for contact ulcers

Voice therapy and reflux management

76)

4 types of neurogenic voice disorders

1. VF paralysis2. spasmodic dysphonia3. degenerative diseases4. other neurological conditions

77)

How to classify vocal fold paralysis

Unilateral or bilateral?abductor (can't open) or adductor (can't close) type?

78)

What causes VF paralysis?

Heart issues or strokedamage varies depending on nerve effected

79)

What happens when the recurrent laryngeal nerve is damaged?

Can't open or close vocal folds

80)

What is stridor

Noisy breathing

81)

3 phases of VF paralysis

1. acute- immediate flaccidity of VF on same side as nerve2. intermediate- partial recovery of function3. chronic- 4th or 5th month, degeneration of damaged nerve, improvement is seen

82)

What is spasmodic dysphonia?

Involuntary spasms of the laryngeal muscles during speech

83)

Prime population for spasmodic dysphonia

Gradual onset in mostly young to middle-aged womenpeople used to think it was stress related but now have placed it in the neurogenic V.D. category

84)

Etiology of spasmodic dysphonia

Signal that goes to the vocal folds is not working properly

85)

Treatment for spasmodic dysphonia

Used to send you to counseling, now do botox injections into VF's

86)

3 types of spasmodic dysphonia

1. abductor2. adductor3. mixed

87)

Abductor spasmodic dysphonia

VF's blow apart inappropriatelyless common typemay have tremorsmay be confused with muscle tension dysphoniamore trouble with voiceless consonants (hard to bring VF's together for voicing following a voiceless consonant)voice sounds breathy and quiet since VF's are open more

88)

Adductor spasmodic dysphonia

VF's slam together and stiffen (may stay closed for too long)more common typevaries from day to day or within a dayvoice sounds strained/strangled, voice breaksdystonia (sudden, abnormal movements, esp. in singing)

89)

Mixed spasmodic dysphonia

Combination of adductor and abductor types

90)

Treatment for neurogenic voice disorders caused by degenerative diseases (i.e. Parkinson's)

Use Shout Therapy, Lee Silverman Voice Treatment (gold standard), or Think Loud

91)

What other neurological condition could cause a neurogenic voice disorder?

Cerebral palsy

92)

Strutural voice disorders

Can occur at variety of ages or in both gendersminor to fatalcongenital or acquired

93)

2 types of structural voice disorders that we discussed

1. laryngeal web2. papillomata

94)

Laryngeal web

Wedding between vocal foldssmall web: hoarse, high pitch, may be trouble breathingdo surgery to divide web

95)

What is a complete laryngeal web called?

Complete laryngeal atresia

96)

Papillomata

Benign, wartlike growths within larynsmore common in juvenilesviral (related to HPV)hard (wart) or soft (glistening, pinkish) mass on VF'saggressive (keeps growing & occurring) or nonaggressive (happens once)can be fatal

97)

Treatment for papillomata

Surgery and voice therapy

98)

Symptoms of papillomata

Hoarse, breathy, maybe trouble breathing

99)

What is a psychogenic voice disorder?

Disordered voice due to disordered emotionsanxiety, depression, major traumaranges from hoarseness to aphonia

100)

2 examples of psychogenic voice disorders

1. puberphonia2. conversion voice disorder

101)

Puberphonia

Mutational falsettovoice remains high-pitched in males

102)

Conversion voice disorder

Loss of voluntary voice due to stress/conflicttreatment: behavioral management and counseling

103)

Who could be on the team for assessing a voice disorder?

SLP, ENT, neurologist, allergist, nutritionist, respiratory therapist, etc.

104)

Steps in Ax of voice disorders

1. referral2. case history3. describe speech behaviors4. describe other relevant behaviors5. stimulability- voice change probes6. decision making & goal setting

105)

Information to obtain in a case history

Medical info, history of speech and voice disorders, describe problem, onset, how variable is problem, describe daily voice use & note any abuse, additional info

106)

Examples of other relevant behaviors to obtain in Ax of voice disorders

Oral mech. examhearing testscreen for any lang. or artic. issues

107)

The gold standard for Ax of voice is ___ Ax!

Perceptual- ears are your best instrument

108)

Things to assess when looking at voice

Breathing, pitch, loudness, quality, resonance

109)

3 types of breathing

1. thoracic- chest moves in & out (panting)2. clavicular- shoulders move in & out3. diaphragmatic- diaphragm contracts; need for speech

110)

What can you make the patient do to show you his optimum pitch?

Yawn, sigh or hum

111)

3 types of pitch to look at in Ax of voice

Habitual (everyday)optimum (ideal for age, gender)range (use singing up and down the scale to determine)

112)

3 description's of client's vocal registers (pitch)

1. pulse- glottal fry/low pitch2. modal- ideal, mid range3. loft- high pitch

113)

Examples of special pitch problems

Diplophonia (using false & true VF's- babies)falsetto (very high pitch)vocal frymonopitch

114)

3 problems with loudness

Too loud (sensorineural HL)too soft (conductive HL)monoloudness (no range in loudness)

115)

3 ways to perceive vocal quality

1. s/z ratio2. reading passage3. conversation

116)

What to listen for in perception of voice quality

Breathiness (too much air)harshness (effort in voice)hoarseness (vocal nodules)tremor (shaky)

117)

What is the CAPE-V

Consensus of auditory perceptual evaluation of voicedeveloped via ASHA initiative

118)

The CAPE-V is a potential ___ instrument for evaluating voice quality

Standardized

119)

6 parameters of the CAPE-V

1. overall severity- global, integrated impression of voice deviance2. roughness- perceived irregularity of voice3. breathiness- audible air escape in voice4. strain- perception of excessive vocal effort (hyperfunction)5. pitch- perceptual correlate of fund. freq.6. loudness- perceptual correlate of sound intensity

120)

Objective Ax measures for voice disorders

Referral to ENTindirect view of larynxendoscopy (videostroboscopy or LVES)- oral or transnasal typesENT may order biopsy

121)

3 interdependent approaches for voice disorder intervention

1. medical (surgery, radiation, meds, psychiatry)2. environmental (modify or reduce conditions that damage voice)3. direct (direct vocal rehab)

122)

7 things involved in direct approach Ix of voice disorders

1. listening skills2. personal hygiene3. mental hygiene4. posture & movement5. regulation of breathing6. relaxation7. voice training

123)

Direct approach: listening skills

Self-monitoring!listen for voice misusepitch recognition and discriminationmatch sounds of various pitches, etc.

124)

Direct approach: physical hygiene

Decrease vocal abuses (throat clearing, etc.)hydration!diet changessufficient exercisereflux: elevate head of bed and sleep with mattress at an angle

125)

Direct approach: mental hygiene

Counseling: speak in common terms, explain why their voice is different, refer to psychologist as needed

126)

Direct approach: posture and breathing

Sedentary occupationslose abdom. muscle control for respiratory efficiencyshoulder droopdemonstrate correct breathing techniques (diaphragmatic)

127)

Direct approach: relaxation

1. easy onsets- pre-voice exhalation, start with vowels then words phrases and sentences2. laryngeal tension- glottal fry, imagery, /h/ words, relaxation exercises, meditation, deep breathing, humming, massage outside larynx, biofeedback

128)

Direct approach: voice training

1. pitch changes- humming, raise & lower pitch, pitch warm ups2. intensity- too loud, too soft, LSVT3. hold phonation and gradually increase duration when relaxed

129)

Vocal function exercises (VFE)

Dr. Joe StempleVocal warm ups, pitch glides & prolongations of /o/ at selected pitchesAppears to have effective treatment outcomes

130)

How does the LVES work?

Has a strobe light to see VF movement in slow motion

131)

Chronic laryngitis

Mostly smooth, straight VF edgesdiffuse inflammation and rednessstiff VF movement

132)

Muscle tension dysphonia

Tension of laryngeal with false fold movement towards midline obscuring view of true vocal foldsvoice= strained and rough

133)

Vocal fold bowing

VF's do not meet at midline during voicingatrophy of VF edgesvoice= breathy & strained

134)

What is the #1 vocal abuse?

Clearing your throat

135)

What does the visi-pitch measure?

Pitch & volume (objective)

136)

What is the s/z ratio?

's' measures airflow and 'z' measures voiceGreater than 1.2 ratio may indicate a voice problemfor holding 's' normal time is 15-20 sec. should be able to sustain 'z' for just as long

137)

Types of voice therapy (from guest lecture)

Eliminate vocal abusesvocal function exercisesear trainingeasy voicinglaryngeal massagedecreasing or increasing loudnessresonant/forward focus voice

138)

Who might be on the team for cleft lip & palate?

SLP, OT, craniofacial surgeon, orthodontist, pediatric dentist, pediatric neuropsychologist, nutrician, etc.

139)

3 parts of the palate

1. alveolar arch2. hard palate3. soft palate

140)

Which muscle of the soft palate has a eustachian tube function?

Tensor palatini