Добавил:
Sekretar
kiopkiopkiop18@yandex.ru
t.me/Prokururor I Вовсе не секретарь, но почту проверяю
Опубликованный материал нарушает ваши авторские права? Сообщите нам.
Вуз:
Предмет:
Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_4506_Библиотеки_им_академика_М_И_Перельмана.pdf
336 The Voice and Voice Therapy
Overview of the Pharyngoesophageal Segment
When discussing alaryngeal speech, it is just as important to appreciate the anatomy and physiology of the PE segment as it is to understand the larynx when learning about voice. The name
of the PE segment essentially defines its location. This segment is also known as the neoglottis
(or new glottis); following a total laryngectomy, it is bounded by the pharynx superiorly and the
esophagus inferiorly. It is composed of three distinct muscles: the inferior pharyngeal constrictor,
cricopharyngeus (CPM), and uppermost esophageal muscle. This segment is highly variable in
location, length, shape, and tone among individuals (Ramaswamy et al., 2022); it is tonically
contracted at rest and relaxes only during swallowing, vomiting, and burping.
When discussing the PE segment, the following are true:
●
The PE segment is typically visible through an endoscope.
●
There are numerous shapes (circular, triangular, split side to side, split anterior to
posterior, and irregular) as defined by its open-phase configuration.
●
This segment is capable of vibration (vibration is defined by site, e.g., posterior wall,
anterior wall, left or right wall, or all walls).
●
Saliva may be visible (none, slight, moderate, and severe).
●
A traveling wave may be seen.
●
Vibration may be regular or irregular.
●
There is a predominating phase (open, closed, and equal).
copy or high-speed digital imaging (HSDI). Because this PE segment is surgically created at the
time of the total laryngectomy, understanding its shape, configuration, and vibratory characteristics may promote optimal alaryngeal voice in the future. This advancement appears likely only
through future research utilizing HSDI of the PE segment.
PluralPlus
Self-Check
9–5
producing sound, three distinct images of PE segment vibration during stroboscopy are presented
in Figures 9–14, 9–15, and 9–16.
Summary
In this chapter, we considered the types or modes of cancer treatment (radiation, surgery, and
chemotherapy) and their effect on the voice. Some case examples that demonstrate the voice treatment approach used with patients undergoing each method of treatment were considered. Factors
such as vocal fold dryness and stiffness as well as absence of tissue after treatment were discussed.
VFAs, which have been successful in producing vocal improvement in patients who have been
treated for laryngeal cancer, were listed.
have been diagnosed with laryngeal cancer was presented. The treatment approaches for patients
who undergo total laryngectomy were also provided. The methods used and references for further
information on these approaches were covered. A variety of ALs both past and present were
presented. Methods of esophageal speech and TEP speech production were provided in detail.
These descriptors are similar to observations made in true vocal fold vibration using strobos-
To afford the reader a better understanding of the PE segment and how and why it is capable of
The importance of topics such as vocal hygiene and preoperative teaching for patients who
CHAPTER 9 Management and Therapy Following Laryngeal Cancer 337
F IGU R E 9 14. Vibrating neoglottis during stroboscopy in TEP
speech.
FI GUR E 9 15. Vibrating neoglottis during stroboscopy in TEP
speech.
338 The Voice and Voice Therapy
F IGU R E 9 16. Vibrating neoglottis during stroboscopy in TEP
speech.
GUIDED READING
Read the following article:
Maniaci, A., La Mantia, I., Mayo-Yáñez, M., Chiesa-Estomba, C. M., Lechien, J. R.,
Iannella, G., . . . Cocuzza, S. (2023). Vocal rehabilitation and quality of life after total
laryngectomy: State-of-the-art and systematic review. Prosthesis, 5(3), 587–601. https://
doi.org/10.3390/prosthesis5030041
Describe four ways in which the information reported in the article might influence your
clinical practice.
CHAPTER 9 Management and Therapy Following Laryngeal Cancer 339
PREPARING FOR THE PRAXIS
Directions: Please read the case study and answer the five questions that follow.
Mr. O presents with a squamous cell carcinoma of the larynx that is described by his
ENT physician and oncologist as large and penetrating. In addition, CT scans have
identified multiple lymph node involvement of greater than 6 cm.
1. This cancer would be described as:
A. T4, N3
B. T2, N1
C. T1, N3
D. T2, N2
2. Due to the advanced stage of the carcinoma, the most likely intervention
recommendation is:
A. Laryngectomy
B. Radiation only
C. Hemilaryngectomy
D. Chemotherapy only
3. Which of the following statements is true concerning the three major communication
options available to Mr. O after laryngectomy?
A. Tracheoesophageal speech employs lung air.
B. Esophageal speech impounds more air in the upper esophagus than
tracheoesophageal speech.
C. Only esophageal speech employs the pharyngoesophageal segment.
D. They are mutually exclusive.
4. The attribute that would render Mr. O a likely candidate for successful
tracheoesophageal (TE) speech use would be:
A. Little to no fibrosis
B. A history of multiple radiation interventions
C. Extensive flap reconstruction
D. Esophageal stricture
5. Mr. O needs to know the following about the pharyngoesophageal (PE) segment:
A. He may need to undergo a cricopharyngeal myotomy.
B. The PE segment always takes on a circular configuration during open phases.
C. He needs strong finger pressure at the stoma to set the tissue into vibration.
D. The PE segment cannot be observed with stroboscopy.
CHAPTER 10
RESONANCE
DISORDERS
LEARNING OUTCOMES
After reading this chapter, one should be able to:
●
Describe the differences among hyper-, hypo-, and assimilative nasality.
●
Define clinical approaches that can be used to evaluate resonance disorders.
●
Describe the various instrumental assessments of velopharyngeal function and cite
their advantages and disadvantages.
●
Be familiar with surgical and prosthetic treatment of resonance disorders.
●
Describe behavioral approaches that address voice and speech in resonance
disorders.
341
342 The Voice and Voice Therapy
esonance in speech is shaped by the acoustic properties of the vocal folds and the unique
configuration of the speaker’s vocal tract, which includes the pharynx, oral cavity, and
R
the vocal folds and enhancing certain frequencies to create the rich and varied sounds of speech.
The process begins with the vocal folds, which produce a basic sound or voice. This voice is then
modified by the vocal tract, which can amplify or dampen certain frequencies based on its shape
and size. This modification is what produces the distinctive resonances of vowels and consonants.
An essential component in this process is the velopharyngeal (VP) valve. Proper function of this
valve ensures that the balance of oral and nasal resonance is suitable for the particular sound being
made. For instance, the VP valve must close adequately to prevent nasal resonance when producing
most vowels and voiced consonants in English, which are typically oral sounds. However, the valve
remains open for nasal consonants like “m,” “n,” and “ng,” allowing air and sound to resonate in
the nasal cavity.
balance of oral and nasal sound energy that matches the intended speech sound. This balance
varies not just with different sounds but also across different languages and dialects. An acceptable
range of resonance exists, and within this range, resonance is perceived differently by each listener.
resonance disorders occur. These disorders can be due to structural anomalies, functional issues,
or even mislearned speech patterns, and they can significantly affect speech intelligibility and
quality. Speech-language pathologists (SLPs) distinguish between these causes to tailor treatment
effectively.
nasal cavities. These structures act as a filter, modulating the basic sound generated by
In speech-language pathology, resonance is considered normal when there is an appropriate
When this balance is disrupted, resulting in too much or too little nasal or oral sound energy,
Disorders of Nasal Resonance
Resonance disorders present with a spectrum of signs and symptoms that can be identified and
analyzed by an SLP. These vary according to the specific disorder and its underlying causes. For an
SLP, understanding these characteristics is crucial for accurate diagnosis and effective intervention.
Hypernasality is a condition marked by excessive nasal sound resonance. This is most noticeable on vowel sounds and certain consonants such as glides and liquids. When hypernasality is
pronounced, it can even affect voiced oral consonants like /b/, /d/, and /g/. High vowels such as
/u/ and /i/ are often the first to reveal hypernasality. It is essential for SLPs to perform a differential
diagnosis to distinguish between resonance issues arising from anatomical challenges, such as those
following cleft palate repair, and those stemming from learned speech patterns. Velopharyngeal
dysfunction (VPD), involving the improper transmission of sound into the nasal cavities due to
VP mechanism issues, can lead to hypernasality, among other speech characteristics such as nasal
air emission and decreased intraoral pressure.
Hyponasality is a condition marked by a diminished nasal resonance, particularly influencing
vowels, sonorants, and nasal consonants. When severe, it may lead to denasalization, causing nasal
sounds to be produced more orally; for instance, /b/ may replace /m/, /d/ may replace /n/, and
ŋ
/g/ may replace /
Cul-de-sac resonance occurs when the vocal resonance is trapped in a cavity — be it nasal,
oral, or pharyngeal — due to an obstruction like enlarged tonsils. This blockage leads to muffled
/.
CHAPTER 10 Resonance Disorders 343
and indistinct consonant sounds and generally reduced speech volume. When the nasal cavity is
involved, the speech may have a distinctive “tinny” quality.
Mixed resonance is a complex condition involving the simultaneous presence of hypernasality,
hyponasality, and/or cul-de-sac resonance. This can cause fluctuations in speech resonance, with
hypernasality and hyponasality alternating during connected speech, as seen in conditions like
apraxia. Additionally, a combination of VPD with a nasopharyngeal obstruction can lead to the
concurrent appearance of hypernasality and hyponasality.
Assimilative nasality, also known as contextual nasality, occurs when a non-nasal sound
becomes nasalized due to the influence of adjacent nasal sounds in speech. This typically happens
because of the proximity of nasal phonemes to non-nasal phonemes within a word or phrase. For
ŋ
example, if a nasal consonant like /m/, /n/, or /
/ appears next to a vowel or a non-nasal consonant,
the non-nasal sound may take on a nasal quality. For example, appreciate the difference in nasal
quality between the words band versus bag. The /a/ and /d/ in band assimilate the nasality of the
/n/. Assimilative nasality is a normal phonological process that often occurs in speech development in children but can also be present in dialectal variations of language in adults. However,
if excessive or inappropriate, it might be considered a speech disorder and could be addressed in
speech therapy.
The diverse nature of resonance disorders requires SLPs to employ a range of assessment
techniques and develop individualized therapy plans. Recognizing the specific characteristics and
PluralPlus
Self-Check
10–1
underlying causes of each disorder allows for more effective treatment and better outcomes for
patients. This personalized approach is crucial, as it caters to the unique needs of each individual,
ensuring that therapy is both relevant and impactful (Kummer, 2020).
Comprehensive Assessment of Nasal Resonance Disorders
There are more similarities than differences between patients with resonance disorders and
those with phonation disorders. For this reason, many of the evaluation procedures outlined in
Chapter6 are equally relevant here. In addition to obtaining the necessary medical data (such
as what treatment has already been provided), clinicians must pursue case history information (description of the problem and its cause, description of daily voice use, variations of the
problem, onset and duration of the problem, etc.). Clinicians must observe closely how well the
patients seem to function in and outside the clinic. Considering how subjective our judgments of
resonance disorders are, it is crucial that clinicians know how their patients perceive their own
voices. A mild resonance problem, for example, can be perceived by a patient or others as severe,
but a severe resonance problem, at times, may be ignored. We have known of adults with unrepaired clefts of the palate that had markedly severe hypernasality and had come to accept their
vocal quality as normal.
Case History
In assessing resonance disorders, the SLP carefully reviews the individual’s family and medical
history, noting any incidences of cleft palate or related surgeries, and looks for patterns of VPD
or speech-language disorders within the family. Developmental milestones and any neurological
344 The Voice and Voice Therapy
conditions are also taken into account, alongside past speech-language interventions, including
those after cochlear implant. The patient’s history with hearing loss and any treatments, genetic
conditions, feeding difficulties, nasal regurgitation, or breathing issues provide essential context.
The SLP considers the duration, consistency, and triggers of the resonance problem to inform a
comprehensive treatment plan. For detailed guidance, refer to the American Speech-LanguageHearing Association’s (ASHA) Practice Portal on resonance disorders (https://www.asha.org/
practice-portal/clinical-topics/resonance-disorders/).
Audiological Assessment
In the clinical setting, the SLP consults with an audiologist, who can initiate a detailed auditory
examination with an otoscopic exam to inspect the ear canal and tympanic membrane. They
conduct immittance testing to evaluate middle ear function, essential for detecting conductive
hearing issues that may affect speech resonance. Pure-tone audiometry is utilized to identify the
degree and type of hearing loss, while otoacoustic emissions tests investigate cochlear health,
particularly the function of the outer hair cells. Word and speech recognition tests are then administered to determine the patient’s auditory discrimination skills, crucial for tailored speech therapy.
These evaluations form a comprehensive auditory profile that informs the SLP’s intervention
strategies. See ASHA’s Practice Portal on Hearing Loss in Children for more information (https://
www.asha.org/practice-portal/clinical-topics/hearing-loss-in-children/).
Oral Mechanism Exam
In evaluating resonance disorders, a comprehensive structural assessment of the craniofacial
complex and oral structures is essential. This evaluation includes examining facial symmetry,
the oral cavity, and the VP mechanism for any structural differences or abnormalities. Key areas
of focus include the symmetry, strength, and mobility of the lips, jaw, tongue, and soft palate;
the condition and size of tonsillar tissue; and any evidence of past surgical interventions. These
observations provide critical insights into potential factors affecting resonance and guide the development of targeted speech therapy interventions. See ASHA’s Practice Portal on Comprehensive
Assessment for Resonance Disorders: Typical Components for more information (http://slps.biz/
index-1646.html).
As important as the oral examination is in patients with articulation disorders, it is less so
for most patients with VP disorders. Oral examination provides a limited amount of information
about the strength, range of motion, and degree of VP function because the anatomical point
of closure is superior to the lower border of the velum. That is, the clinician cannot actually see
the nature of velar and pharyngeal function simply by viewing the mechanism through the oral
cavity. For example, poor uvular-tip contact with the posterior pharyngeal wall does not indicate
lack of closure more superiorly in the pharynx, where closure may actually occur. Conversely, the
contact of the uvula to the posterior pharyngeal wall is not necessarily an indication of adequate
VP function. A markedly short, sluggish, or flaccid soft palate can certainly be noted on direct
inspection of the oral cavity, and such a notation is a diagnostically important indicator for further
evaluation of VP function. To truly determine the degree, speed, accuracy, and range of motion of
the velopharynx, however, direct observation of the entire system is necessary.
CHAPTER 10 Resonance Disorders 345
By direct visualization of the oral structures, the clinician can make a gross observation of the
relationship of the velum to the pharynx; note the relative size of the tongue; make a judgment
about maxillary–mandibular occlusion; view the height and width of the palatal arch; survey the
general condition of mucosa, faucial arches, and dentition; and determine if there are any clefts,
open fistulas, or evidence of submucous cleft. Oral inspection of the tongue is critical because some
problems of functional nasality may be related to inappropriate size of the tongue in relation to
the oral cavity, poor or posterior tongue carriage, or irregular tongue movement due to an upper
or lower motor neuron lesion.
The clinician should make a thorough search for any openings of the hard or soft palate
that might contribute to an articulation distortion or to some problem of nasal resonance. Some
patients have small openings (fistulas) or lack of fusion around the border of the premaxilla,
particularly in the area of the alveolar ridge. In some individuals, such fistulas may produce
airstream noises, creating articulatory distortion (by loss of intraoral air pressure), but almost
never do such isolated openings this far forward on the maxilla produce nasal resonance. The more
posterior the palatal fistula, the greater is its effect on nasal resonance.
The absence or presence of soft-palate and hard-palate clefts should be noted; if such clefts
have been previously corrected surgically, the degree of closure should be noted. In the case of a
bony-palate defect, for example, sometimes the bony opening has been covered by a thin layer of
mucosal tissue that is not thick enough to prevent oral cavity sound waves from traveling into the
nasal cavity. This same observation applies to the occasional submucosal cleft at the midline of
the junction of the hard and soft palates. The major signs of a submucosal cleft are bifid or split
uvula, inverted A-shape defect in the velum, lack of a palpable posterior nasal spine, or a thin
soft palate (which may appear darker in color) in the midline portion. Any other structural deviations — of dentition, occlusion, labial competence, tongue control, and so on — should be noted
and considered with regard to their possible effects on speech production and nasal resonance.
Perceptual Analysis of Speech
An obvious way to begin the evaluation of someone with a nasal resonance disorder is to listen
carefully to their voice during conversation. This can provide a gross indication of what the
problem may be. The perceptual aspect of nasal resonance disorders is extremely important. In
fact, as reported by Bettens and colleagues (2016), several authorities on resonance consider assessments as the standard against which instrumental measurements must be validated. It is important
to note, however, that it is difficult to make a clinical judgment about nasality by listening to
someone as they speak in real time; in fact, such a judgment is likely to be wrong. For example,
in a seminal study of perceptions of nasality, a group of researchers found that neither a group of
four experienced judges nor a group of four inexperienced judges could reliably judge the recorded
voice samples of children producing /a/ and /i/ with nares open and closed (by digital pressure).
This may not be too surprising because both vowels are basically non-nasal in English. The judges
were similarly unreliable when judging nasality from conversational speech samples. Although the
casual judgment that “something is nasal about the speech” is usually correct, not all examiners
can quickly and reliably differentiate the type of nasality (hypernasality, assimilative nasality, and
hyponasality) on the basis of such a conversational sample alone. Voice quality judgments are
more accurate if made on the basis of recorded samples of a patient’s conversational speech, their