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LIN2358 Final: Communication Disdorders- Notes Final

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University of Ottawa
agathe Rheaume

Page 1 LIN2358A Communication Disorders Final Exam: March 22 2017 CLASS 8- Voice Organic Voice Disorders Phonotrauma (vocal abuse) : any habit that hinders the appropriate and safe process of phonation • smoking • drinking alcohol and caffeinated beverages (coffee, tea, Coke/Pepsi) – diuretics • talking too loud for a long time • whispering for a long period of time • speaking at the wrong pitch talking too much • • clearing your throat or coughing incessantly • tension in the vocal cords • inadequate breathing • dehydrated vocal cords (medication, not drinking enough) • gastric reflux Vocal fold paralysis • can be caused by many different situations (surgery, treatment, unknown cause, etc.) • Teflon or botox can be injected in the paralysed vocal fold to make it thicker and lessen the space between the two vocal folds • in certain cases, therapy can be done to help make phonation more efficient Spasmodic dysphonia • a permanent voice disorder of a neurogenic nature • can occur to people in their thirties Adduction type Spasms in vocal folds; intermittent aphonia; strained-strangled voice; difficulty in • phonating; • monotone, monopitch and monoloudness; shaky voice Vocal nodules • softer small formations that develop on the vocal folds as a result of vocal abuse can lead to a hoarse voice or intermittent pitch and phonation breaks • Vocal polyps • can appear when blood vessels rupture and swell as a result of vocal abuse • contrary to nodules, polyps can be the result of a single intense shouting event • leads to a hoarse and breathy voice Page 2 Contact ulcers • lesions caused by vocal abuse • can cause pain Laryngeal webs • membrane connecting one cord to the other • congenital or caused by scar • needs surgical approach Papilloma • hard wart-like masses • can be removed surgically, but can come back Cancer of the larynx • usually, the whole larynx needs to be removed surgically due to the cancer (laryngectomy) • the trachea is then moved to form a stoma (opening similar to a mouth) in front of the neck for breathing Ways to talk after after a laryngectomy: • we need a new sound source (alaryngeal speech) Artificial larynx • external sound source created by device • pressed against neck or cheek Oesophageal voice/speech • “burping” in a controlled manner – it produces a sound which is very similar to that of vocal cords Tracheooesophageal prosthesis • Helps the air go from the new airway to the oesophagus • Allows the speaker to use the air from room air and one of the muscle of oesophagus (cricopharyngeus) to produce voice Psychogenic voice disorders Hysterical/Conversion aphonia • a person who has a strained, dysphonic voice, as a result of an intense emotional state • these changes are automatic and involuntary • strong emotions, especially when repressed, could, in certain limited situations, cause psychogenic voice disorders • vocal cords can be normal in appearance • they can work normally for functions that are not related to speech (i.e., coughing) • they don’t function when the person tries to speak • usually, people with this type of disorder whisper instead of using a regular voice • this type of problem is generally diagnosed as an organic trouble until the therapist realizes that the person does not react in an expected manner to the treatment Page 3 Consequences of voice disorders • Negative reactions • Avoidance • Anxiety, depression • Effect on intelligibility • Effects on professional, social life CLASS 9- Fluency Disorders Normal Dysfluency: Normal speech may be interrupted by: • pauses • hesitations • repetitions • prolongations (lengthening/stretching) 
 In certain situations, it can be accompanied by secondary behaviours such as: • a lack of visual contact • facial tightness/grimaces • movement of the body (hands, arms, legs) that happen while the person is trying to deal with challenging situation Fluency disorders When fluency goes from normal to abnormal, other behaviors, of a more emotional nature, may occur: • The person may be embarrassed or afraid to lose control of speech. • As a result, people who are dysfluent will avoid social situations and those where they have to speak. • These feelings may have a severe impact on their personal and professional life. 
 All dysfluencies should not be considered as abnormal. Frequent?( are they happening a lot) Permanent? (does it vary or is it always there) Abnormal dysfluencies may include: • pauses • hesitations • interjections - ouh, ah, um • whole-word repetitions Page 4 Dysfluency Abnormal dysfluencies may include: • whole-phrase repetitions • sound repetition - initial sound ex: sssssnake • false starts: start and they readjust • revisions/corrections: start and stop, or start and change the word , and you do it in a permanent way Observable behaviors of dysfluency – Overt (and frequent) signs • Whole-word repetitions • Part-word repetitions • Sound prolongation (s-s-s-seven) • Interjections (uhh, ah) • Hard onset of words ex: POWer - instead of just power Observable behaviours of dysfluency– Overt/Primary signs • Difficulty with breathing/air flow that causes blocks (with tension) • Problems with initiating phonation: starting, voicing or pronunciation of the consonant • Unusual oral musculature movements: movement of the face, twitch kind of like the apraxic person Observable behaviours of dysfluency – Associated/Covert/Secondary • Inconsistent visual contact: doesn't keep eye contact • Head movements : added movements look away, look down • Limb movements : unusual limb movement • Body movements: sitting down might start moving one leg and then the other to switch positions Observable behaviours of dysfluency – Associated/Secondary • Circumlocutions • Describing a word: go around the word if they can’t say that specific word • Word substitutions : substitute the words for another • Facial grimaces Cluttering • Another form of dysfluency Page 5 • Less common • A fluency disorder characterized by a rapid and/or irregular speaking rate and excessive dysfluencies (The Stuttering Foundation website) 
 Characterized by: • A quick rate • Sudden accelerations • A lack of pauses • Numerous repetitions • Articulatory imprecisions • Syllable clipping (“ferchly” for “fortunately”) • Reduced intelligibility CLASS 10- Hearing Part 1 The audiologists Screens, evaluates, treats and helps prevent the following problems: • Hearing deficits (including APD – auditory processing disorder [central auditory processing disorder] – formerly CAPD) • Problems with balance (vertigo) • Tinnitus • Etc. Where do they work ? • Hospitals and Rehab centres • Private clinics • Hearing Aid Companies • Representatives/Sales • Training • Research • University • Research • Teaching Related professions • Teachers • Specialized teachers • Speech-language pathologists • Ear, nose and throat doctors (ENT) and Otologists • Hearing instrument specialists (HIS) • Engineers Page 6 Sound and Hearing Sound • Energy transmitted through waves of pressure in air, liquid or solid • Physical phenomenon Hearing • Perception of a sound • Psychological (neurological) phenomenon Production of a Sound: Required conditions Examples - Speech Energy source Air exhaled from lungs Something that can vibrate Vocal cords Environment that can help Air transmit the vibration Characteristics of sound Intensity • Measured in decibels (dB) • Expresses a ratio; 0dB does not mean the absence of sound • Subjective perception of loudness: loud vs. quiet Frequency • Measured in Hertz (Hz) • Number of cycles per second • Subjective perception of pitch: high vs. low What the human ear can hear • Between 20Hz et 20000Hz in a young adult • For speech, we use mostly sounds between 200 and 8000 Hz Pure and complex sounds • Pure sounds are rare in everyday life • Used in audiology for testing • Speech is a complex sound The auditory system The peripheral system • The external ear • The middle ear Page 7 • The internal ear The central system • Brainstem • Cerebral auditory areas The external ear Auricle/Pavilion • Visible part; « the ear » • Made of cartilage covered with skin • Brings sounds to the canal External auditory canal • 2-3 cm long in an adult • Not straight, angled • Contains glands that secrete cerumen (wax) • 1st third (external): skin-covered cartilage • 2nd and 3rd third (internal): skin-covered bone Roles of the external ear • Amplification • Localization • Protection Amplification • Transfer fonction • Modification of intensity • Gain of 5 and 10 dB, according to frequencies (between 1500 and 7000 Hz) • The auricle acts as an antenna; it captures sounds and brings them to the EAC Localization • The sounds that are captured by the right ear are usually different from the ones captured by the left ear • The brain compares the information that comes to both ears and this is what helps us localize sound sources • lip reading is actually called speech reading- articulation, facial expressions ; we all do it Protection Protects the eardrum • The EAC becomes smaller and smaller as it gets closer to the eardrum Cerumen (ear wax) • Protects from dust and bugs • Lubrifies the EAC • May have antifungal properties Page 8 The middle ear The eardrum (tympanic membrane) The ossicles • Malleus, incus, stapes The tympanic cavity The Eustachian tube (or auditory tube) The eardrum Membrane located at the entrance of the middle ear The majority of the eardrum’s surface is made up of 3 layers: • Cutaneous layer (external) • Fibrous layer (part of it only) • Mucous layer (internal) The ossicles The smallest bones of the human body • Malleus (hammer): the handle is connected to the eardrum • Incus (anvil) • Stapes (stirrup): the faceplate of the stapes rests on the oval window of the internal ear Suspended by ligaments and tendons in the cavity of the middle ear Roles of the middle ear • Transforms acoustical energy (vibrations of air molecules) into mechanical energy • Protects the ear from loud noises (limited) • Balances the ear pressure on either side of the eardrum • Why do we need to amplify a sound signal? • Hint 1: there is liquid in the internal ear… • Hint 2: sound goes from an air to a liquid environment … • Loss of energy! Protection against loud noises through the stapedial reflex Contraction of the stapedial muscle (connected to the stapes) • Makes the tympanic-ossicular chain more rigid • Reduces the amplification normally caused by the vibration of the ossicles In audiology, we use it to verify the integrity of certain structures of the auditory system. • Involves structures of the brainstem and cranial nerves VII and VIII The stapedial reflex (the stapes bone) The protection of the internal ear by the stapedial reflex is limited: • Reflex can weaken due to fatigue • Delay before it kicks in • Only triggered by low and middle frequencies (2000 Hz or less) (only some frequencies) Roles of the middle ear Page 9 • The Eustachian tube: • Connects the middle ear to the nasopharynx • Helps balance the pressure on either side of the eardrum • i.e.: when in a plane • Also helps to evacuate the secretions of the middle ear and aerate the cavity of the middle ear CLASS 11- Hearing Part 2 The internal ear • Converts mechanical energy (movement of the ossicles) into nervous influx • Is located in cavity of temporal bone The internal ear (the parts of it) • The cochlea (hearing) • The vestibular system (balance) - vertigo The cochlea In the shape of a snail, goes around itself 2.5 times in humans Filled with liquid Composed of two labyrinths: • Outer (made of bone and filled with perilymph) • Inner (made of a membranous material and filled with endolymph) The organ of Corti • Inside the inner labyrinth • Sensory part of the cochlea • Holds the sensory receptor cells of the hearing system: the hair cells (and many other structures) • The hair cells are located on the basilar membrane (which makes up the floor of the organ) • The basilar membrane moves and vibrates with the liquids of the internal ear when there is a sound stimulus (different parts react to different frequencies of sounds: high – closest to the stapes; low – portion near the tip) The hair cells • They are sensory cells • They are innervated by the fibres of the vestibulocochlear nerve • Are covered with stereocilia Summary • The piston-like movement of the stapes moves the perilymph (creates a wave), which makes the inner labyrinth move. • The wave moves along the cochlea and makes the basilar membrane vibrate. • The movement of the basilar membrane stimulates the hair cells, which trigger nervous influx. Page 1 0 • The mechanical energy of the middle ear is then transformed into hydraulic energy and then in an electrical signal Auditory nerve • Cranial nerve VIII: vestibulocochlear nerve • Composed of the nerve fibers of the internal ear involved in hearing (cochlear) and balance (vestibular) • Made up of ascending and descending fibres • The fibres go to the brainstem • Limit of the peripheral hearing system The central auditory system • The brainstem • The auditory cortex (and other parts of the brain) • Nerve fibres bring the influx along the different parts of the central auditory system Audibility vs intelligibility • Audibility: detection • ”I heard something.” • Intelligibility: recognition and comprehension • Comprehension of speech Types of peripheral hearing loss • Conductive loss • Sensorineural loss • Mixed loss Conductive hearing loss • Also called transmission loss • Involves one or more structures of the external and/or middle ear • Sounds become less audible • Can sometimes (even often) be treated medically • People with that type of loss often report: • “I have to turn up the sound on the TV.” • “I can’t hear the small sounds anymore (quiet sounds).” Sensorineural hearing loss • Due to a problem with the internal ear • Often at the level of the hair cell • Usually permanent • Audibility is affected, but intelligibility is also compromised • Loss of clarity • High frequencies (high-pitch sounds) are often affected • People with that type of loss often say: • “I can’t hear voices clearly.” • “I hear, but I don’t understand.” Page 11 Mixed loss • Loss with a conductive and a sensorineural component Levels of hearing loss • Hearing threshold: • Most quiet sound that a person can detect at least 50% of the time. • Measured in dB HL (hearing level) CLASS 12- Hearing Part 3 Pathological conditions of the ear • Not all pathologies will have an impact on hearing and therefore communication. Conditions of the external ear • Cerumen impaction or other foreign bodies in the external auditory canal • Temporary • Usually easy to treat: irrigation/syringing • By a doctor, a nurse or an audiologist Hearing threshold Level of loss 10 to 15 dB HL Normal 16 to 25 dB HL Normal for adults Very mild for children 26 to 40 dB HL Mild 41 to 55 dB HL Moderate 56 to 70 dB HL Moderately-severe 71 to 90 dB HL Severe >90 dB HL Profound Cerumen impaction • More common in older people • To remove the impaction, NEVER use: • Q-tips • Candles (ear candling) • Bobby pins or similar objects… (yes, it does happen) Page 1 2 Pathological conditions of the external ear • Atresia of the EAC • Absence or occlusion of the EAC • Microtia of the pinna often present • Congenital • Stenosis of the EAC • Narrowing of the EAC • Can be congenital or acquired (more rare) • Does not necessarily cause a hearing loss • Atresia and stenosis often associated to a syndrome External ear: external ear infection • Inflammation of the pinna and the EAC • Caused by a bacterial infection, sometimes fungal, or a dermatitis • Symptoms • Pain • Oedema/Swelling • Discharge Pathological conditions of the middle ear: otitides • Infections of the middle ear: inflammation of the mucosa of the middle ear • Serous infections • Acute infections • Chronic infections • The accumulation of fluid in the middle ear (behind the eardrum) can lead to a perforation of the eardrum Middle ear: perforation of the eardrum • Can be caused by: • Otitis media • Object inserted in the ear • Burn • Trauma • Etc. • The eardrum can heal itself (scars will form) Middle ear: otosclerosis • Excess of spongy bone tissue • Often hereditary • More frequent in women • Often seen during or following a pregnancy • Symptoms often appear between 20 and 40 years old • Often bilateral • Hearing loss is often progressive and can be accompanied by tinnitus • The most commonly affected area is the faceplate of the stapes Page 1 3 • Growth of spongy bone tissue around the stapes, which fixes the faceplate in position and prevents the piston-like movement • Treatment: stapedectomy • Surgery to replace the stapes Middle ear: disarticulation • Disarticulation of the ossicular chain • Separation of the ossicles in one of many places • One of the ossicles can fracture, but rarer • Most often due to a traumatic brain injury, but can also be caused by an object inserted into the EAC • Reconstructive surgery possible Middle ear: cholesteatoma • Accumulation of keratin and fat in the middle ear • Often associated with a perforation of the eardrum • Can cause the erosion of the ossicles • Requires a surgery Pathological conditions of the internal ear • Prenatal infections (TORCH) • Toxoplasmosis (come from cat litters, create neurological problems) • Other • Rubeola (extinct now, like chicken pocks) • Cytomegalovirus (virus, not on the exam) • Herpes • Perinatal conditions or illnesses • Postnatal conditions (affects children only) • Presbyacusis • Hearing loss caused by aging • Bilateral and symmetrical (affect the entire hearing system) • High frequencies (high-pitched sounds) affected first Internal ear: Ménière’s disease • 3 symptoms: • Hearing loss • Tinnitus (can cause pain/anguish) • Vertigo • Hearing loss often in low frequencies • Fluctuating symptoms Internal ear: Ototoxicity • Many medications have a toxic effect on the ear: • Cancer drugs, antibiotics, diuretics, other (aspirin) • Tinnitus often present • Very high frequencies are often affected first Page 1 4 • Hearing loss is often reversible (depends on the agent, the dose and many other factors), but often permanent Other conditions that can affect the internal ear • Trauma, fractures • Syndromes • Acoustic neuroma • Genetic • Idiopathic Other: cochlear implants are also conditions to help the internal ear. CLASS 13- Assessment Consent • To control decisions regarding your medical care • To help protect your personal information • Implied consent: consent which is not expressly granted by someone, but which is inferred from a person’s actions (or lack thereof) and the facts and circumstances of a particular situation (or in some cases, by a person’s silence or lack of action). • Informed consent: process for getting permission before conducting a healthcare intervention on a person. *you have to make sure the person is able to give consent. Screening • To determine who is at risk for having a loss, a difficulty. ex: Red Cross. • Pass or fail criteria • False positives, false negatives • For example: • adults who are 60 and over • preschool children • newborns Assessment • Collecting background information • From the referral… • Reading a chart (need permission) • Interviewing client; significant others; staff • Other tests, investigations • Start of problem • Previous similar problem • Etc. *never assume, assess thoroughly Physical Examination Page 1 5 • Audiology • Otoscopic examination: small handheld device; to verify general status of structures; anatomy, cerumen impaction, inflammation, presence of object; video-otoscope which allows projection of image onto a computer/tv screen and printing of images • otoscope is the instrument with a little light used by audiologists to look in the ear • Speech-language pathology • Swallowing: tongue depressor and pen light; oromotor examination • Speech: oromotor examination • Voice: vocal cords; laryngoscopy done by ENT • Timing is everything! Involving the client and others • Often good to have input from others who have a different perspective from person being assessed • Especially in situations when problem may affect perception or insight • Spouses and children can be helpful • Focussing on client (patient centered work) Specific Assessment Procedures • Audiology • Electroacoustic Testing: record acoustic s
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