Swallowing Disorders in Adults

If you have ever found yourself saying, “my drink went down the wrong pipe”, it typically means it went down your trachea, which may lead to aspiration. Aspiration is the entry of food, liquids or saliva past the vocal folds potentially into the lungs; it is more frequently observed when swallowing fluids. Symptoms typically include coughing, difficulty breathing, and in some cases choking. Normally, everyone encounter’s this process every once in a while due complications coordinating the respiratory and digestive mechanisms. However, individuals with swallowing disorders experience this type of pain and discomfort on a regular basis, which places them at heightened risk for life-threatening complications, such as pneumonia, blood infections, or lung abscess.

Swallowing disorders, also known as dysphagia, may be defined as the difficulty with the transportation of liquids, solids, or both from the pharynx to the stomach. Individuals may encounter difficulty transporting hard textured foods while others have difficulty drinking liquids. Dysphagia, occurs in all age groups and may be a result of a variety of congenital abnormalities, structural damage, or medical conditions. Such conditions typically include, Cerebral Vascular Accidents (CVA), nervous system disorders (i.e., Parkinson’s Disease, Multiple Sclerosis, Cerebral Palsy, respiratory complications, esophageal complications including gastroesophageal reflux (GERD), Traumatic Brain Injury (TBI), head and neck cancer, etc. Other conditions may include intake of antihistamine medication or associated psychological behaviors.

The following are typical signs and symptoms of dysphagia:

  • Inability to recognize food
  • Coughing before, during, or after the swallow
  • Difficulty managing food within the oral cavity
  • Sudden weight loss
  • Change in vocal quality (gurgly/wet)
  • Pain when swallowing (odynophagia)
  • Gastroesophageal Reflux (GERD)

The four phases of swallowing that encompass the transportation of food to the stomach. 

  • Oral Preparatory Phase: the formation of the “bolus” or chewed up food
    • Sensory recognition of food or identification that it’s in front of them
    • Rotary chew pattern/movement and manipulation of the consistency to form a cohesive ball or “bolus”
    • Lateralization the tongue and chewing with the back molars for bolus formation
  • Oral Phase: the movement of the “bolus” from the front to back of the mouth
    • Tongue pushes the bolus backwards
    • Labial closure while chewing to prevent food from lip spillage
    • Cheek tension increases to inhibit pocketing of food and increase tension for bolus formation
  • Pharyngeal Phase: the transportation of the “bolus” from the top of the pharynx to the bottom of the pharynx
    • Vocal fold closure and downward movement of the epiglottis to cover entrance into larynx for airway protection
    • Velopharyngeal closure to prevent regurgitation (food to going back up nasal cavity)
    • Laryngeal excursion is the upward and forward movement of the larynx and hyoid bone while the upper esophagus is opening to help bolus move down. Additionally, it helps to protect the airway by pulling it out of the way.
    • Pharyngeal walls contract (pharyngeal constrictors) to help push the bolus through to the bottom of the pharynx
  • Esophageal Phase: encompasses the passage of the “bolus” from bottom of the pharynx to the stomach
    • Peristalsis is the action of the esophageal muscles to help push the bolus down the esophagus to the stomach
    • Referral to a gastroenterologist is typically the most appropriate for patients experiencing esophageal stage dysphagia

 

Ashley F, M.S., CF-SLP TSSLD

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The Late Talking Toddler

A late-talking toddler typically presents with an established foundation of language learning. This foundation includes receptive (comprehension) language, fine motor, gross motor, and play based language skills. However, they continue to demonstrate limited or no expressive (production) language skills.  Although every child’s development is unique to their “own rate” of progression when compared to their age matched peers, there are certain ranges of development that certain milestones should occur.  Some children seem to catch up on their own, while others do not. Therefore, parents and early development professionals should remain cognizant of the typical progression of speech and language development.

Critical language milestones to keep in mind for your toddler:

  1. First Word – Children produce their first meaningful word for communicative intent around 12 months, around the time they begin to walk.
  2. Combining Words – Most children have approximately 50 words and begin to combine 2-word phases at 24 months (i.e., mommy up, no milk, more ball).
  3. Asking Questions – Children begin to use intonation to ask yes/no questions and demonstrate use of wh- questions around 12 – 26 months of age.
  4. Prepositions – Children typically use about two or three prepositions (i.e., on, in, out) by 12-24 months of age.
  5. Intelligibility – Children around 2-3 years of age should be approximately 50-75% intelligible by an unfamiliar listener.

Some parents may decide to wait and see if their late-talker will catch up to their peers. However, they typically struggle to determine whether their child’s language skills are typical or atypical due to the wide age variation of development. However, it is never too early to schedule and evaluation with a speech-language pathologist to determine whether your child is on the right track! The speech-language pathologist will talk to you about your concerns and determine if intervention is necessary. Intervention may be necessary if the speech-language pathologist notices risk factors that would inhibit future language learning and may suggest intervention or early intervention.

The following are a few risk factors in future language difficulties:

  1. History of being quiet as an infant
  2. Limited number of early developing consonant sounds (e.g., /p, b, m, t, d, n/)
  3. Limited vocabulary use
  4. Lack of verbal imitation
  5. Difficulty playing with others
  6. A family history of communication delay, learning or academic difficulties

Research suggests there are some late-talking toddlers who seem to catch up on their own without intervention by the time they enter school. However, they continue to perform at a lower level than their peers in certain aspects of language (i.e., literacy, grammar). Seek advice from a professional and schedule an evaluation with a speech-language pathologist to address your concerns. In addition, they may offer suggestions and tips to practice language learning at home and support your child’s expressive language development.

Get Ready for Back to School with these Fun Language Activities

As we approach the end of the summer, there remains plenty of opportunities for parents to target their child’s language skills in preparation for the upcoming school year! After a summer of adventure and freedom, language-based activities can be enjoyable while enhancing your child’s overall academic, social, and emotional well-being.  Check out the following activities that can be used throughout your child’s everyday activities!

  • Story Time: Shared story reading is the best way to promote overall academic by targeting communication, language form/use, and literacy skills. Shared reading is powerful interactive approach involving participation of both the parent and child. As the parent demonstrates proficient reading skills, they involve the child through active participation. This type of involvement will help improve the child’s lexical repertoire (vocabulary), print awareness, as well as the sound correspondences between written and spoken words. In addition, shared reading targets a child’s attention skills, conversational skills, and verbal reasoning. To target their critical thinking skills, ask your child to predict what will happen next or reason why something happened.
  • Treasure Hunt: This activity is the simplest way to enjoy a beautiful day with your kids! Take a few household objects and make a list of descriptive words to describe each item as well as the location (behind a chair, under the statue) they will be hidden in your backyard! Give your child the list of clues and have check off each item as they find each item. Additionally, this activity can be modified to target articulation skills if the objects hidden include the targeted sound. For example, to target the /s/ sound: scissors, can of soup, sunscreen, sunflowers, necklace, sock, etc.
  • Go on a picnic: This type of activity is great to target vocabulary, sequencing, descriptive words, and following directions! Have your child gather and identify all needed items to go on a picnic (basket, utensils, napkins, cups). Then, create a menu for the lunch you will want to bring on the picnic. For example, if you are bringing sandwiches, have your child identify the ingredients needed. Then, together write down sequenced steps to create the sandwich. Last, have them follow the directions to create their desired sandwich!
  • Watch a Movie: What a better way to target language skills than to watch a movie on a rainy day! After watching a movie, conduct a family discussion and have your child provide a recap of the movie. Their recap may include, description of the characters (protagonist, antagonist) and their personalities, discussion of the main idea, sequencing the movie scenes, discussion of both your favorite part and your child’s favorite part (or not so favorite part) of the movie, etc.
  • Re-cap the Summer: Discuss all the exciting adventures you and your child have completed over the summer. This helps prepare your child to answer those ice breaker activities typically introduced in the beginning of the school year to begin conversation and help children establish rapport with their peers. Some questions may include:
    • Something fun you did this summer
    • Name a cool/fun place you visited
    • Talk about a new hobby
    • What is something you tried for the first time?
    • What was your favorite thing to do? or Did you find something new that is your favorite thing to do?
    • What do you expect to learn this year?

 

 

Ashley F. M.S., CF-SLP TSSLD

How to communicate after a laryngectomy

The ability to speak is a complex procedure that involves several parts of the body. These include the mouth, the articulators (tongue, teeth, hard palate, soft palate, lips), the respiratory system and the brain. Sometimes, people may experience trauma that affect their ability to speak appropriately. Examples of this include a cardiovascular accident (CVA or stroke) or head and neck cancer. When the trauma is severe and speech is severely affected, SLPs and doctors may opt to remove the larynx. The larynx, commonly known as the voice box, houses the vocal folds giving us the ability to speak. Once the larynx is removed, our ability to speak is impaired. However, there are alternative approaches to speaking once the larynx is removed.


The first is esophageal speech (ES),which is when air is inhaled into the pharyngoesophageal (PE) segment and then expelled into the esophagus. This expulsion brings the PE tissue into vibration thus creating voice. Although it is not implemented frequently, it is essential for SLPs to have an understanding of ES. It can be taught in two different ways: injection and inhalation.  The injection method prepares the patient for ES by producing voiceless sounds, attempting esophageal phonation and demonstrations of ES by the SLP. In this stage, the patient gains phonatory skills with ES, such as precision and speed. In the inhalation method, air intake and esophageal phonation are improved. In order for the best results, it is best to teach the inhalation method in conjunction with the injection method.


The second option is the electrolarynx, which involves the use of an external instrument placed against the throat or oral structures. The electrolarynx can also be placed in the oral cavity to facilitate speaking. The electrolarynx falls under the category of an artificial larynx (AL), which is what most patients who undergo a laryngectomy prefer postoperatively. Clinicians recommend using an AL in the immediate days following surgery.


The third and last option is tracheoesophageal (TEP) voice restoration surgery. The surgery can either be performed during the time of the laryngectomy or after surgery. A puncture is made to the posterior wall of the trachea through the anterior wall of the esophagus. Prosthesis is inserted into the puncture and shunts air from the lungs into the esophagus. This causes the upper esophageal sphincter and surrounding tissues to vibrate, thus the sound for voice is created. The pulmonary air is essentially forced to eject through the esophagus. The patient first practices phonation with single words, then phrases. It is important to note that the patient breathing effort remains the same as it did preoperatively.


Overall, all 3 forms of alaryngeal speech are alternative modes to communication after a laryngectomy. AL requires an external instrument for communication while ES and TEP rely on supplementary structures to communicate (i.e. esophagus, pharynx, articulators). ES and TEP are similar since the esophagus is the main mode of communication however; TEP is the only form of alaryngeal speech that requires additional surgery, which is usually done during the time of the laryngectomy.

-Ashley E. M.A, CF-SLP

Cluttering

What is Cluttering?

Cluttering is a fluency disorder where an individual speaks at a rapid rate, and/or with an irregular speaking rate and demonstrates excessive dysfluencies such as blocks, repetitions, prolongations, etc. Other symptoms can include language or phonological (sound pattern) errors as well as attention deficits. Although there is no “cure” for cluttering, an individual can learn and implement certain techniques to improve speaking rate, language skills, and attention.


Symptoms

The following are some common symptoms of cluttering:
• Rapid rate (talking too fast)
• Overarticulation of words (putting additional emphasis on speech sounds)
• Inappropriate breaks in speech patterns (pauses where there shouldn’t be pauses)
• Monotone speech (little inflection—sounding like a robot)
• Excessive dysfluencies/stuttering behaviors

Additional symptoms that may or may not be present include lack of awareness of the problem, family history of fluency disorders, poor handwriting, confusing and disorganized language or conversational skills, temporary improvement when asked to “slow down” or “pay attention” to speech, misarticulations, poor intelligibility, social or vocational problems, distractibility, hyperactivity, auditory perceptual difficulties, learning disabilities, and apraxia.


How to treat Cluttering

A speech-language pathologist can provide treatment for cluttering. The following are some ways to treat cluttering:

• Start treatment by encouraging the person to speak slower, allowing the person to “control” the rate of speech.                                                                                                 • Use visual aids such as a speedometer for monitoring the rate of speech—Keep
speech rate below the “speed limit.”
• Begin with highly structured utterances such as “Hi, my name is ___.” Then, move
toward a more typical flow of language and conversation.
• Have the person who clutters exaggerate stressed syllables in words and articulate all syllables. The goal is to have the individual learn to self-monitor his/her speech.
• Have the person who clutters listen to a disorganized speech sample and then listen to a sample of clear speech to increase awareness of the correct production.

Ashley E. M.A., CF-SLP

Velopharyngeal Dysfunction (VPD)

What is VPD?

Velopharyngeal Dysfunction (VPD) is a condition where the velopharyngeal valve does not close consistently and completely during speech sound production.


Three Types of VPD

  1. Velopharyngeal insufficiency (VPI): a structural defect that prevents adequate velopharyngeal closure. This is the most common type of VPD, as it includes a short or abnormal velum. This occurs in children with a submucous cleft or cleft palate.
  2. Velopharyngeal incompetence (VPI): a neurophysical disorder which results in poor movement of the velopharyngeal structures. This is common in individuals with dysarthria due to cortical damage or velar paresis due to cranial nerve damage.
  • Children with VPI may demonstrate hypernasality(too much soundin the nasal cavity), nasal air emission (leakage of airduring consonant production) and compensatory articulation productions (abnormal articulation productions in the pharynx to compensate for a lack of oral air pressure due to VPI).
  1. Velopharyngeal mislearning: lack of velopharyngeal closure on certain sounds due to the use of sounds in the pharynx as a substitution for certain oral sounds.
  • Children with velopharyngeal mislearning may produce pharyngeal sounds as a substitute for oral sounds. This causes nasal emission due to the placement of production.

When is Speech Therapy Necessary?

  1. Speech therapy cannot change abnormal structure and therefore, cannot correct hypernasality or nasal emission due to VPI— even if there is only a small gap! VPI requires physical management such as surgery, or a prosthetic device.
  2. Speech therapy is beneficial when nasal emission or hypernasality is caused by placement errors.

What is done in Speech Therapy

  • Use a “listening tube” (even a bending straw), have the child put one end of the tube in the entrance of a nostril and the other end near his ear. When nasality occurs, it is heard loudly through the tube. Ask the child to try to reduce or eliminate the sound coming through the tube as he produces oral sounds and then words.
  • Bring awareness to the abnormal production versus the target sound. Give as many clues as possible using visual, tactile and auditory feedback.
  • Have the child produce the phoneme /p/ and then a vowel preceded by an /h/. For example, /p…hɑ/ for /pɑ/ and /p…ho/ for /po/. This keeps the vocal folds open during transition to the vowel and prevents the production of the glottal stop.

Ashley E. MA, CF-SLP

Ten Principles of Grammar Facilitation for Children with Specific Language Impairments

Introduction

  • This article focuses on grammatical morphology (i.e. omission of copulas, auxiliaries, articles, regular tense inflections) because it is heavily researched in the field and is a consistent deficit in children with Specific Language Impairment (SLI).
  • SLI is a language disorder that delays the mastery of language skills in children who have no hearing loss or other developmental delays.
  • Because of its pervasiveness, SLPs are often asked to develop intervention plans targeting grammatical morphology however, they have difficulty developing intervention plans that consider other areas of weakness the child has or potential areas of weakness the child may develop.
  • Ten principles were developed to facilitate “state of the art” grammatical interventions.

Principles

  1. The basic goal of all grammatical interventions should be to help the child achieve greater facility in the comprehension and use of syntax and morphology in the service of conversation, narration, exposition, and other textual genres in both written and oral modalities.
  2. Grammatical form should rarely, if ever, be the only aspect of language and communication that is targeted in a language intervention program.
  3. Select intermediate goals in an effort to stimulate the child’s language acquisition processes rather than to teach specific language forms.
  4. The specific goals of grammatical intervention must be based on the child’s “functional readiness” and need for the targeted forms.
  5. Manipulate the social, physical, and linguistic context to create more frequent opportunities for grammatical targets.
  6. Exploit different textual genres and the written modality to develop appropriate contexts for specific intervention targets.
  7. Manipulate the discourse so that targeted features are rendered more salient in pragmatically felicitous contexts.
  8. Systematically contrast forms used by the child with more mature forms from the adult grammar, using sentence recasts.
  9. Avoid telegraphic speech, always presenting grammatical models in well-formed phrases and sentences.
  10. Use elicited imitation to make target forms more salient and to give the child practice with phonological patterns that are difficult to access or produce.

Summary

  • The purpose of these ten principles is to assist in the of development of interventions that foster grammatical development.
  • These intervention methods should be broad enough to note improvement in the child’s overall communicative, behavioral, social and academic performance.
  • While these principles are meant to guide intervention, the SLP should still consider each child’s individual strengths and weaknesses when administering therapy.

Ashley E. M.A., CF-SLP

Reference:

Fey, M. E., Long, S. H., & Finestack, L. H. (2003). Ten principles of grammar facilitation for      children with specific language impairments. American Journal of Speech-Language          Pathology, 12(1), 3-15.