Speech, Language, Voice and Swallowing Therapy Clinic

VOICE DISORDERS

How is voice produced?

The structure commonly known as the "Adam's apple" is at the front of the larynx. The vocal cords extend backward from the Adam's apple. When we breathe out, there is an airflow from our lungs toward the larynx. This air passes between our vocal cords. If we close our vocal cords during this airflow, the vocal cords vibrate and sound is produced.

What is normal voice?

Normal voice is one in which a person's voice quality, pitch and loudness are similar to those of individuals of similar age, gender, cultural background and geographic location, and which is appropriate for communication.

What is a voice disorder?

A voice disorder occurs when a person's voice quality, pitch and loudness begin to differ from those of individuals of similar age, gender, cultural background and geographic location. When, for structural, functional, or both reasons, the speaker's laryngeal mechanism cannot meet the voice demands, a voice disorder should be suspected.

What factors cause voice disorders?

The factors that affect the voice production mechanism and cause voice disorders are very diverse. Voice misuse habits (speaking loudly, shouting, frequently clearing the throat, etc.), medical causes (laryngectomy, thyroid surgery, intubation, heart surgery, etc.), chronic diseases (respiratory problems, hormonal problems, stomach problems, allergies, etc.), habits (alcohol and cigarette use) or neurological disorders are the most important causes of voice disorders.

Is treatment/therapy for voice disorders possible?

When a voice disorder occurs, a physician examination is required first. The physician will help you with diagnosis and will apply medical treatment when needed, or will refer you to a speech and language therapist when voice therapy is needed; because speech and language therapists apply voice therapy techniques so that some voice conditions can be prevented, improved and not recur.

What is voice therapy?

Voice therapy is a program aimed at teaching patients how to produce the best possible voice using their voice system, how to recover from injury or disease, and how to protect themselves. It promotes the balance of voice production physiology, assists breath coordination, and includes exercises to ensure the appropriate pitch, height and voice quality needed for voice production and the health of the vocal cords. As part of a rehabilitation program, it is a preventive approach aimed at reducing or eliminating environmental effects and behaviors that could harm the voice, and ensuring the necessary use and care so that the voice stays healthy. The therapy techniques applied vary according to the disease and its symptoms.

SWALLOWING DISORDERS

What is a swallowing disorder?

A swallowing disorder (dysphagia) is difficulty swallowing that occurs during eating and drinking. A swallowing disorder can occur in three different phases of swallowing:

Oral phase: Problems that may occur during the stage of sucking, chewing, or moving food or drink from the mouth toward the throat

Pharyngeal phase: Problems in closing the windpipe to prevent food or drink from being sent in the wrong direction, i.e., into the windpipe, while sending food or drink into the esophagus

Esophageal phase: Problems that may occur in sending food and drink from the esophagus to the stomach

What are the causes of a swallowing disorder?

A swallowing disorder may result from damage to the nervous system, various problems involving the head and neck region, or diseases:

• Stroke
• Brain trauma
• Parkinson's disease
• Multiple sclerosis
• Cerebral palsy
• Alzheimer's disease
• Mouth, throat or pharynx cancers
• Head and neck surgery
• Oral hygiene problems (missing teeth, use of decayed or unsuitable dental prostheses)

What are the symptoms of a swallowing disorder?

A swallowing disorder has many symptoms:

• Coughing during or immediately after eating or drinking
• A "wet" voice during or immediately after eating or drinking
• Spending more effort or time on chewing or swallowing
• Weight loss and dehydration (lack of water) resulting from inadequate nutrition
• Recurrent pneumonia, or choking while breathing after eating
• Food or liquid leaking from the mouth, or food accumulating in the mouth

How is a swallowing disorder diagnosed?

Speech and language therapists specializing in swallowing disorders evaluate people who have eating and drinking problems. During the evaluation, the speech and language therapist carries out the assessment described below:

• Learning the patient's medical condition and information about the swallowing disorder
• Evaluating the strength and movements of the muscles and structures involved in swallowing (such as the lips, tongue, jaw and palate)
• Evaluating the patient's posture and mouth movements during eating and drinking
• Instrumental evaluation of the swallowing disorder

How is a swallowing disorder treated?

Treatment of a swallowing disorder is planned by the speech and language therapist according to the cause, symptoms and type of the swallowing disorder. During treatment;

• Specialized exercises are performed to strengthen and coordinate the muscles responsible for swallowing, or to stimulate the nerves that can trigger the swallowing reflex
• Various positions and swallowing strategies are applied so that the person can swallow more comfortably
• The person is fed with food and drink of different consistencies so that swallowing is safe and easy

How does a swallowing disorder affect a person's life?

A swallowing disorder can affect a person's life in various ways:

• Inadequate nutrition and dehydration
• Less enjoyment of eating and drinking
• Avoiding social settings involving meals, and feeling embarrassed or withdrawing in such settings
• Risk of aspiration (food or liquid entering the windpipe), which may lead to pneumonia or chronic lung disease

ARTICULATION AND PHONOLOGICAL DISORDERS

What is articulation?

Articulation is the individual's ability to correctly pronounce the speech sounds of a particular language through the coordinated, sequential movements of the organs involved in speech.

What is an articulation disorder?

Articulation disorders are problems based on the incorrect production of the place, form, speed, timing and pressure of speech sounds.

What causes articulation disorders?

Articulation disorders may be of structural origin, but they may also be seen without any specific cause. Causes that may create articulation problems include cleft lip and palate, mouth and face anomalies, orthodontic anomalies, hearing loss, intellectual disability, and neurologically based disorders (cerebral palsy and others).

In articulation disorders, errors may be observed in the following forms:

• Substitution of the /k/ and /t/ sounds for each other, such as /töpek/ instead of /köpek/,
• Substituting other sounds for the /r/, /y/, /l/ and /ç/ sounds
• Using the /t/ and /d/ sounds instead of the /k/ and /g/ sounds

What is phonological competence?

Phonological competence is the ability to use speech sounds in accordance with the rules within the context of a language.

What is a phonological disorder?

Phonological disorders are difficulty in acquiring knowledge of the language rules that form the basis of speech (phonology). The child cannot produce easily understandable speech patterns. For example, the child has not learned to use the /s/ sound at the beginning of words. Developmental phonological disorders may, in later years, contribute to reading and writing difficulties in children.

Is it important to correct articulation disorders?

If the problem has come to affect social, emotional, academic and/or work life, resolving it becomes more important. Therefore, articulation problems should be addressed urgently.

DELAYED LANGUAGE AND SPEECH

Language and speech are different from each other. Language is a system of shared rules that people use to share their feelings and thoughts with one another. A language should not only bring to mind spoken language; writing and sign use are also a language. Speech, on the other hand, is the system in which the rules containing these feelings and thoughts are physically produced with the help of the necessary organs.

A child may have the grammar needed to convey feelings and thoughts, but may be unable to speak because the speech organs (tongue, lips, etc.) cannot perform their function as needed. On the other hand, another child may perform speech organ functions flawlessly but may be unable to speak due to a problem in language development, or both may occur at the same time.

Is my child's delay temporary, or is it a disorder?

Children may lag behind their peers in some skills; they may catch up quickly, or may even do even better. A child may have a delay in speaking while developing normally in skills such as walking, eating, and toilet use. All children have generally accepted, identical or similar developmental stages; in addition, some children may have their own developmental timing and may begin speaking slightly earlier or later than their peers. Parents are quite good observers; they watch their children's behavior very carefully. At the same time, parents also have an idea about the development of other children in their environment who develop normally. When parents suspect something in their child, they compare their child's performance with other children, and most often they realize that something is not going right at the right time. Naturally, they become worried and want to gain clarity, first by consulting their close circle and then a specialist nearby: My child still isn't talking. My child expresses themselves differently. My child's words are not easily understood.

It is difficult for families or non-specialists to determine whether the child's speech is delayed or whether there is a language or speech disorder, and, beyond that, whether the child can overcome this problem on their own.

Language and speech disorders are not a subject that pediatricians, psychologists and child development specialists specialize in, or should specialize in. Your doctor, child psychologist or preschool teacher may advise you to wait without seeing a specialist until your child is 3, or even 4 years old, noting that your child's physical development is normal, that they hear, and that they can produce words such as "daddy" and "mommy". Likewise, experts from various professions know that many children cannot speak at age 2 but begin speaking fluently at age 3, and may therefore ask families not to worry until they see a real problem. This way of thinking leads families to take a "wait and see" approach, and those whose children caught up with their peers turn a similar approach into a kind of soothing folk belief passed from ear to ear:

“Just wait, he'll talk”

”His uncle/aunt/brother, etc. also talked late”

”Einstein also only started talking when he started school”

Yes, although it cannot be proven, Albert Einstein and the other individuals mentioned may have spoken late, and some of them may even have overcome the problem on their own. If you look more carefully around you, you will notice that many children who have reached 5-6 years old, or even school age, still have language and speech problems. Considering that these children also had delayed speech at one point, what then will become of these children who have reached 5-6 years old, or who are still unable to speak like their peers or communicate differently at school age, or in other words, the little Einsteins?

The truth is that studies conducted in many countries show that more than 10% of preschool and school-age children have language and speech disorders. Put simply, this means one out of every 10 children around you. So many of the late-talking older brothers, sisters, uncles, aunts, neighbor's children, etc. that your doctor or those around you cite as examples suffer from language and speech problems. Another known fact is that many children whose speech is delayed continue to have it as a language and/or speech disorder into school age and later in life.

When your car breaks down, the risk you take by accepting the mechanic's reassurances, such as "let's wait and see" or "the neighbor's car also started late," may cost you a bit more money or, at the very most, may lead to losing your car. Well, what about when the matter concerns your child? The risks you take here may lead to social, psychological and behavioral problems and learning difficulties that become increasingly difficult to reverse as the child grows older. So, if you suspect a delay, disorder or difference in your child's communication, it is very important to have a language and speech disorders specialist evaluate your child and, if necessary, ensure they receive education.

What should families do?

Families should not waste time listening to what non-specialists say, or assuming in a relaxed manner that their children will in any case catch up with their peers in terms of speech. If you suspect a problem with your child's language or speech development, consult a speech and language disorders specialist. The speech and language therapist will measure the child's understanding and expression of spoken language with the help of tests, evaluate the child's communication with their environment in a natural setting, identify factors that may affect development, and provide the family with counseling on what they should do from then on.

Why should I consult a specialist?

Even for something simple, waiting is a burdensome process; waiting to see whether a child will be able to speak is an even harder and more distressing process. Knowing that a problem can be solved more easily and quickly when it is noticed at an early stage is a bad feeling for families.

Even if your child has only a simple delay, you should consult a specialist therapist instead of believing hearsay. The speech and language therapist will comprehensively evaluate your child's language and speech skills and, as a result, will send you home with many ideas for strengthening your child's communication skills beyond "wait and see," or will want to check on them at regular intervals.

FLUENCY DISORDERS IN SPEECH

What is rapid-disorganized speech (cluttering)?

Rapid-disorganized speech (cluttering), briefly defined as speech that is abnormally rapid and irregular, is still being studied by researchers today.

Rapid-disorganized speech is a speech fluency disorder like stuttering, but it differs from stuttering. It is a speech disorder involving excessively rapid, irregular speech, often containing words or phrases unrelated to the topic.

In rapid-disorganized speech, the normal flow of speech is excessively interrupted, and this may be accompanied by excessively fast speech, irregular tempo, incorrect/incomplete articulation and uncertainty about what one is going to say.

At present, therapies aimed at slowing down speech, reducing disfluencies, and increasing awareness and language organization are applied for rapid-disorganized speech (using techniques used in stuttering therapy).

Explanations made for the causes of stuttering are also being applied to the causes of rapid-disorganized speech, and its frequency of occurrence has not yet been clearly determined.

STUTTERING

Stuttering, which is described in various sources with emphasis on different aspects, is most clearly defined as the disruption of the flow or rhythm of speech by interruptions or blocks. The definition can be expanded as follows:

Stuttering arises as a result of involuntary neuromotor disruptions that affect breathing, phonation (voicing) and articulation coordination during speech. Stuttering, although not always, generally appears as

1) an involuntary loss of control that the person experiences while saying words,

2) excessive and/or abnormal sound or syllable repetitions, prolongations, audible or silent blocks, or avoidance of these behaviors, and

3) it is linked to, or triggered by, many different psychological stresses and negative emotions.”

WHAT IS SPEECH THERAPY AND HOW CAN IT HELP?

Individuals of any age with a language or speech disorder can receive special training from a speech and language therapist who has specialized training in this field. This special training is known as "speech therapy." Speech therapy for stuttering is typically an individual therapy between the person who stutters and the speech therapist. In some cases, family members may also join the therapy sessions, especially if the person who stutters is a child. Speech therapy can also take place in a group setting with more than one person who stutters, for example with 2 to 6 participants. The aims of speech therapy are quite varied. These are listed as: teaching speech in a way that stuttering cannot always occur (fluency shaping); teaching an easier way of stuttering (modification of stuttering); teaching the person who stutters to accept their stuttering or not to avoid it (desensitization and non-avoidance); and other techniques

ACQUIRED LANGUAGE DISORDER: APHASIA

What is aphasia?

Aphasia is a language disorder that usually appears suddenly as a result of a stroke or head trauma and arises from damage to the brain areas responsible for language. In most people, the language areas are located in the left hemisphere of the brain. Therefore, in aphasia, while the language areas on the left side of the brain are damaged, the person may also have a stroke/paralysis on their right side.

This disorder can affect reading and writing as well as the ability to express and understand language. Neurological speech disorders such as dysarthria or apraxia of speech may also accompany aphasia.

What are the causes of aphasia?

Aphasia results from damage to one or more of the brain's language areas. Most often, the cause of brain damage is a stroke. A stroke occurs when a region of the brain is deprived of blood. Brain cells die when they cannot receive their normal blood supply, which carries oxygen and essential nutrients. Other causes of brain damage include severe blows to the head, brain tumors, brain infections and other conditions affecting the brain.

How is aphasia diagnosed?

Aphasia is usually first noticed by the doctor treating the person who has suffered brain damage (neurologist). If the doctor suspects aphasia after a brief bedside assessment, the patient is referred to a speech and language therapist to evaluate communication skills in more detail. The speech and language therapist administers an aphasia test to evaluate in detail the individual's abilities to "follow commands, answer questions, name objects and maintain conversation," and to prepare an appropriate therapy program. The evaluations should include the aphasic individual's motor speech disorders, language comprehension, reading, writing, swallowing competence, and ability to use alternative and supportive communication systems. In Turkey, the following assessment tests prepared for individuals with aphasia are available: GAT (Gülhane Aphasia Test: Tanrıdağ, 1993), GAT-2 (Tanrıdağ, Maviş, Topbaş, 2011), EAT (Atamaz, Yağız On, Durmaz, 2007) and ADD (Maviş and Toğram, 2007).

What is aphasia therapy like?

In some cases, aphasia improves without intervention. This type of spontaneous recovery occurs following a type of stroke in which blood flow to the brain is temporarily interrupted but quickly resolves, known as a transient ischemic attack. In these cases, language abilities may return within a few hours or a few days.

However, for most cases, language recovery is not so rapid or complete. Many people with aphasia experience partial spontaneous recovery, with some return of language abilities within a few days to a month, while in some people aphasia may be permanent. In such cases, speech and language therapy is helpful. Relative improvement usually continues for more than two years. Most health experts believe that the most effective treatment should begin in the early stages of recovery. Factors affecting recovery include the affected area of the brain, the extent of brain damage, and the person's age and health status. Motivation, hand dominance and education level are also among the other factors.

Speech and language therapists who work with aphasia are experts in improving the communication skills of individuals with aphasia by rebuilding language abilities as much as possible, compensating for language problems, teaching other ways of communicating, and motivating them to use their remaining language skills. Individual therapies prepared specifically for each person's aphasia type and impairment focus on the person's functional needs. Group therapies give aphasic individuals the opportunity to use new communication skills in a small group setting. Family participation is also an important component of aphasia therapy.

MOTOR SPEECH DISORDERS: DYSARTHRIA AND APRAXIA

What are motor speech disorders?

Speech is a sensory and motor process that develops through hearing and the use of the mouth-face apparatus, and that requires complex neural integration and rapid coordination of many physiological systems. Speech disorders caused by a neuromotor problem affecting one or more of the respiration, phonation, resonance, articulation and prosody components of speech are called motor speech disorders. There are two types of motor speech disorders: dysarthria and apraxia.

What is dysarthria?

Dysarthria is a motor speech disorder resulting from damage to the central nervous system and/or peripheral nervous system, in which the muscles controlling the speech mechanism show spasticity, flaccidity, coordination impairment or paralysis, affecting the respiration, phonation, resonance, articulation and prosodic features of speech and thereby limiting intelligibility.

APRAXIA

What is apraxia?

Apraxia is the inability to perform skilled movements, apart from conditions such as weakness, akinesia, abnormal tone or posture, impairments in cognitive functions, reduced comprehension, or inability to cooperate. It is a form of motor agnosia.

What is apraxia of speech (verbal apraxia)?

It is a motor disorder of speech programming that occurs in adulthood and childhood. The adult form occurs after normal language and speech development. Childhood apraxia of speech arises as a result of structural brain damage. It is also described as a sensorimotor speech disorder. It is a motor planning disorder in the central nervous system, required for producing words and achieving voluntary muscle movements.

What are the characteristics of apraxic speech?

Articulation problems are frequently seen. In addition, phonation coordination, frequency and/or stress are affected. The patient is aware of their impairment; the problem increases as word length increases. Articulation errors are inconsistent; repetitions, prolongations or variations in word substitutions are seen. Articulation of consonants is harder than that of vowels, and initial consonants are harder than final consonants. Especially with automatic and frequently used words, parts of speech that are articulated perfectly are often encountered.