1. Anne G. Lefton, M.A. / CCC-SLP Nancy Sedat & Associates
2011 Annual Membership Meeting
SPEECH & SWALLOWING
Anne G. Lefton, M.A. / CCC-SLP
Nancy Sedat & Associates

2. “It feels like there’s something stuck in my throat!”

3. Swallowing Transference of material from: Mouth Throat Esophagus
Stomach

4. 3 Phases of Swallowing
Oral
Pharyngeal
Esophageal

5. Normal Swallow Sequence

6. Normal Swallow Sequence
In the mouth:
lips, teeth and tongue help prepare bolus (food mass) for further stages of swallowing.
Lips
Teeth
Tongue
Bolus

7. Normal Swallow Sequence
Access between the nasal cavity and mouth closes as bolus moves into pharynx (throat).
Nasal Cavity
Pharynx
Bolus

8. Normal Swallow Sequence
Bolus is propelled  esophagus
As esophagus entrance opens: Epiglottis helps guard against access to the lungs.
Epiglottis
Vocal Cords
Trachea/Airway to the Lungs
Esophagus Entrance

9. Normal Swallow Sequence
The airway reopens and the esophagus entrance closes as muscle contractions move bolus toward stomach.
To the Stomach

10. Swallowing Disorders

11. Swallowing Disorders / Dysphagia
Oral Stage
Difficulty controlling, forming, or transporting a cohesive bolus

12. Swallowing Disorders / Dysphagia
Pharyngeal Stage
Pooling or Stasis
Aspiration
Illustrations by Elliot Sheltman from Follow the Swallow by Jo Puntil-Sheltman

13. Evaluation of Swallowing Function
Non-instrumental clinical evaluation
Instrumental assessment
Modified Barium Swallowing Study (MBSS)
aka: Videofluoroscopic Swallowing Examination
Fiberoptic Endoscopic Evaluation of Swallowing (FEES)

14. Thin Liquid Swallows

15. Puree Swallows

16. Cookie Swallows

17. Complications from Dysphagia
Pneumonia
Risk increases as dysphagia worsens
Choking
Longer Meal Times
Malnutrition
Dehydration
Weight Loss
Quality of Life
Loss of social interaction associated w/ eating

18. Treatment

19. What to Do? Immediate remedies:
If coughing/choking, never inhibit cough
Heimlich Maneuver
Stack breathing
Portable suction
CoughAssist device [
CoughAssist™ Mechanical In-Exsufflator

20. Safe Swallowing Strategies
Swallowing techniques
Don’t talk with mouth full
Repeat swallows
Alternate solids and liquids
One sip at a time
Sip ‘n’ tip straws
Smaller bites
Slowed rate
Supervision and cueing
Smaller, more frequent meals per day

21. Safe Swallowing Strategies [cont.]
Changes in food & liquid consistencies
Avoid problem textures and consistencies
Gel/powder liquid thickener
Diet Hierarchy
Steak consistency diet
Pot roast consistency diet
Meat loaf consistency diet
Pudding consistency diet
Cream consistency diet (tube feedings)

22. Safe Swallowing Strategies [cont.]
Positioning
Chin tuck
Behavioral changes
Reduce distractions
Eat more calories early in the day or when there is less fatigue

23. Safe Swallowing Strategies [cont.]
Pill management
Take with applesauce, yogurt, pudding, ice cream, or any other slippery medium
Cool Whip!
Long-necked bottles
Carbonated beverages
Crush with pharmacist’s consent

24. Alternative Methods of Nutrition

25. Feeding Tubes
G-tube goes into stomach through an opening in skin

26. Feeding Tubes [cont.] What it does:
Provides nutrition via an alternate route
Allows one to receive required nutrition and hydration when no diet texture can be swallowed safely or when oral feeding is not meeting nutritional / hydration needs
Allows for the combination of oral eating for pleasure and tube feeding for fluids and calories

27. Ataxia and Speech

28. Speech
“Normal” sounding speech requires perfect coordination of the following systems:
Articulatory system (e.g., lips, tongue, etc.)
Resonatory system (e.g., velum/soft palate)
Phonatory system (e.g., vocal cords)
Respiratory system (e.g., lungs)

29. Random Speech Facts…
Approx. 14 different sounds produced every second when we verbalize.
Over 100 different muscles coordinate during speech.

30. “Its Greek to Me”
Ataxia comes from:
Greek word for “lack of order”

31. Ataxic Dysarthria
Disorder of sensorimotor control for speech production that results from damage to cerebellum or to its input and output pathways

32. Effects of Ataxia on Speech

33. Effects of Ataxia on Speech
Articulation: disruption of the timing, force, range, and direction of movements.
Imprecise consonant articulation
Distorted vowels
Breakdown is most evident during longer strings of speech

34. Effects of Ataxia on Speech [cont.]
Resonance:
Hypernasality
Hyponasality
May occur due to timing errors between the muscles of the velum and the other muscles of articulation.
Soft Palate / Velum

35. Effects of Ataxia on Speech [cont.]
Phonation: the sound of the voice
Harsh vocal quality
due to decreased muscle tone
Vocal tremor

36. Effects of Ataxia on Speech [cont.]
Respiration:
Uncoordinated movements of the respiratory muscles
Exaggerated movements
Excessive loudness
Paradoxical movements (different muscle groups work against each other)
Talking too quickly
Decreased vocal volume
Trying to talk on residual air

37. Most Common Speech Changes
Imprecise consonants
Excess and equal stress
Articulatory breakdown
Distorted vowels
Harsh vocal quality
Mono pitch/Mono loudness
Slowed speech rate

38. Treatment

39. What to do about it… 1. Evaluation by a Speech-Language Pathologist
2. Treatment
Exercises will target the affected system(s)
Improve breath support and coordination of breathing and speaking
Rate control techniques (e.g., finger/hand tapping to set the pace of appropriate syllable production)
Increase articulatory accuracy: over-articulate
Develop stress and intonation skills to regulate pitch and loudness

40. Compensatory Strategies
For the Speaker...
Energy conservation
Minimize environmental noise/distractions
Establish context of message
Alter your rate of speech…SLOW it down.
Exaggerate articulation of final consonants in words
Use gestures/point to props
Boil down the message
decrease “filler” words
Keep important/key words

41. Compensatory Strategies
For the Communication Partner…
Ascertain patients preferred strategy when not intelligible
Decrease the need for repetition  fatigue and frustration
Ask yes/no questions
Know the topic
Maintain eye contact
Give undivided attention
Don’t interrupt or finish sentences
Let the speaker know the parts of the message you did not understand so s/he will not have to repeat the entire message.
Patience

42. Augmentative/Alternative Communication (AAC)
Low tech
Communication board
Alphabet board
Phrase board
High tech
Speech generating devices
An SLP can help explore your options
Other
Voice amplification
Chattervox OR SoniVox

43. Take Home Message
With regard to speech or swallowing, there is always a way to keep you functioning at the highest level possible.

44. Anne G. Lefton, M.A. / CCC-SLP Nancy Sedat & Associates
2011 Annual Membership Meeting
THANK YOU!
Anne G. Lefton, M.A. / CCC-SLP
Nancy Sedat & Associates

45. References
Freed, D. (2000). Motor speech disorders diagnosis and treatment. San Diego, CA: Singular Thomson Learning, 2000.
Puntil-Sheltman, J. (1997). Follow the swallow. Seal Beach, CA: Sheltman Publishing,
Rangamani, G.N., J. (2006). Managing speech and swallowing problems: A guidebook for people with ataxia. National Ataxia Foundation, 1-60.
Yorkston, K.M., Beukelman, D.R., & Bell, K. (1988). Clinical management of dysarthric speakers. San Diego, CA: College-Hill Press.