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

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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.

Hearing Loss in Children with Down Syndrome

Hearing loss is prevalent in the Down syndrome population for a variety of reasons. Primarily, there are abnormalities present in the Eustachian tube, ossicular anomalies and remnant tissue in the middle ear cavity that contribute to the presence of conductive, sensorineural or mixed hearing loss in this population (Tedeshi, Roizen, Taylor, Murray, Curtis & Parikh, 2015). A common disease accompanied with middle ear infection is otitis media, which causes conductive hearing loss. Conductive hearing loss occurs when there is a disruption in the flow of sound waves in the outer and/or middle ear. In addition, it is hard to examine the tympanic membrane due to the narrowing of the external auditory canal (Tedeschi et al., 2015).


If hearing loss is a recurring problem in children with Down syndrome, there are various intervention strategies that can be implemented over the span of their life. These intervention strategies include both medical and surgical, such as cochlear implantation and the insertion of pressure equalization tubes. Amplification, such as hearing aids may be an option if medical or surgical intervention is not ideal. Both approaches have led to a decrease in hearing loss in this population. Although hearing loss can never be reversed, research has found the earlier intervention occurs, the more effective it is likely to be.  Early intervention is fundamental for children with Down syndrome accompanied with hearing loss. They are already at a cognitive disadvantage, so receiving therapeutic services from a young age is beneficial in multiple ways. According to the American Speech-Language Hearing Association, early intervention helps children stay on schedule with their speech and language development. If there is a hearing loss, speech may suffer, as there is a disruption in receptive language comprehension. Early intervention can also enhance the child’s awareness of their hearing loss and special communication services. In addition, early intervention allows for the documentation of the child’s progress, which can guide further intervention approaches, such as medical or surgical options. With a knowledgeable clinician, there are an abundance of benefits that children with Down syndrome can receive from early intervention services. (Shott et al., 2001).


In some scenarios, medical and surgical intervention, such as providing medication and the insertion of pressure equalization tubes are not adequate enough to subside the affects of hearing loss in children with Down syndrome. In severe cases, cochlear implantation may be suitable in order to diminish the affects of hearing loss. Cochlear implantation is implemented for severe to profound sensorineural hearing loss. Those implanted at a young age, as early as three months, receive greater benefits because language is developing at a similar rate as their peers. Since children with Down syndrome are prone to several disabilities, it is encouraged to have consistent audiology appointments and to possibly discuss cochlear implantation as early as six months.


References:

Shott, S. R., Joseph, A., & Heithaus, D. (2001). Hearing loss in children with                                 Down syndrome. International Journal of Pediatric Otorhinolaryngology 61(3), 199-205. Retrieved March 20, 2016

Tedeschi, A. S., Roizen, N. J., Taylor, H. G., Murray, G., Curtis, C. A., & Parikh, A. S. (2015). The Prevalence of Congenital Hearing Loss in Neonates with Down Syndrome. The Journal of Pediatrics,166(1). Retrieved March 21, 2016.

-Ashley E., M.A, CF-SLP