Hearing Test Administered Over the Phone

I was just made aware of this service in a Washington Post article published May 16, 2014. This screening hearing test is taken over the telephone and accomplished by listening to three-digit sequences presented in a background of white noise. The test-taker has to then enter the digits using the telephone keypad. Based on accuracy of the response, the test than adjusts the next query.

Normally, the cost to take this telephone hearing test is $8, but at least for the month of May 2014, it is free in celebration of "Better Hearing and Speech Month."

Here's how to take the test by phone:

1. Find a quiet place to take the test that is free from distractions. 
2. If you hang up in the middle of your test, you will have to start from the beginning. 
3. Use a telephone that plugs into a wall-mounted jack. Please do not use a cell phone. 
4. Dial our toll-free number: 1-866-223-7575 
5. Listen to the recorded instructions. 
6. At the end of the test, write down your test results for each ear and the date. The categories are: 

Within the Normal Range

Slightly Below the Normal Range

Poor

Further details of this test can be found here, but the test essentially is based on the speech-to-noise ratio (SNR) that is adjusted using an adaptive procedure seeking a threshold for 50% correct identification of the digit sequences. A set of 25 sequences provides a reliable SNR threshold in about four minutes of testing per ear. This method of testing is different from most hearing tests in that it uses digits in static noise, rather than pure tones. Because the test measures an SNR threshold rather than one based on the absolute level of tones, a reliable screening measure of hearing, despite the differences in sound levels produced by different telephones, can be achieved.

Of note, this method of testing was validated in Europe by scientists at VU University Medical Center in the Netherlands in 2004. The U.S. version began in 2008 with funding from the National Institute of Health and was validated in two studies performed at the Indiana University Hearing Clinic and the other in collaboration with clinics administered by the VA Health System.

If hearing is assessed to be abnormal, you can contact our office to undergo a more sophisticated hearing test for confirmation and next steps.

Source: 
Take this hearing test right now. I did, and the results were disturbing. Washington Post 5/16/14.

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Device that Allows Intubated Patients to Talk

Image by Calleamanecer in Wikipedia

There is nothing worse than to be very sick. It's even worse if you are intubated in the ICU (intensive care unit) being poked and prodded constantly. Traditionally, such sick intubated patients (if alert) will communicate by writing on a clipboard which is often frustrating to not just the patient, but also family members and healthcare professionals trying to care for the patient.

However, NEJM reported on the use of an electrolarynx to allow intubated patients to "talk". Electrolarynx is traditionally used by patients who have had their voicebox removed due to cancer (laryngectomy). Held similarly to a razor, a patient is able to talk by mouthing words while pressing the electrolarynx against the neck The electrolarynx produces vibrations within the throat that allows for speech sounds. See video below to see how it works.

Apparently, this device can also be used by intubated patients to communicate with caregivers. According to the article, speech by intubated patients occurred after only 2 minutes of instruction. Optimal placement of the electrolarynx was between the upper trachea and the sternocleidomastoid muscle. A video is shown in the article webpage demonstrating a patient who is intubated talking using an electrolarynx.

Electrolarynx can be purchased on Amazon.com.

Reference:
Speech in an Orally Intubated Patient. N Engl J Med 2014; 370:1172-1173March 20, 2014DOI: 10.1056/NEJMc1313379

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How Ears Tune In and Out Certain Sounds

Ever wonder how humans with normal hearing are able to "hear" what one person is saying in a crowded room where many people are talking? How is it that the ear is able to tune in and out of conversations going around, especially when everybody in a room is talking equally loud?

To understand this ear "tuning" ability, one needs to first understand that the ear incorporates two "aspects" that allow for good hearing: a volume knob and an antenna. Should the volume knob not work, hearing aids boost the frequencies where hearing loss is present. However, if the antenna does not work, simply increasing the volume does not necessarily make sounds/speech more understandable. This situation is analogous to an old radio where turning the volume up on a station with a lot of static does not make sounds more understandable (fiddling with the antenna to get a clear signal is better).

We have a very good understanding the volume knob of the human ear. What we do NOT have a good understanding (nor how to fix) is the antenna.

However, researchers have begun to clarify how the human ear "fiddles" the antenna to make certain sounds more understandable relative to others providing humans the ability to tune into what one person is saying in a loud restaurant.

Apparently, part of the answer is the tectorial membrane found within the cochlea (membrana tectoria in the Gray's illustration below).

Note that this membrane found inside the cochlea rests on the inner and outer hair cells which allow for hearing (the volume knob). When the ear hears a sound, "waves" are created within the cochlea stimulating the hair cells which allow us to hear. Depending on which hair cells are stimulated, a specific sound frequency is heard.

Using mutant mice, MIT researchers have determined that the viscosity of tectorial membrane depends on the size and distribution of tiny pores. This viscosity provides mechanical filtering that helps to sort out specific sounds by influencing the speed and decay of tectorial membrane waves when a sound is heard.

Although the precise way how the tectorial membrane allows for such exquisite frequency selectivity is still not fully understood, this may be the first step towards that comprehension.

Because once we firmly understand how the ear's antenna works, we hopefully can make better hearing aids that not only act as a volume knob, but can also fiddle the antenna as well.

Reference:
Porosity Controls Spread of Excitation in Tectorial Membrane Traveling Waves. Biophysical Journal, Volume 106, Issue 6, 1406-1413, 18 March 2014 doi:10.1016/j.bpj.2014.02.012

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How to Describe Hoarseness?

At heart, physicians are science geeks. And when it comes to a raspy voice, one can go truly bananas in how exactly to describe how a raspy voice sounds.

For the layperson, when asked to describe a hoarse voice, one often gets imprecise answers to a question most feel ridiculous... I often get a blank look with an answer that goes something like "You know... raspy... it's not clear." Unfortunately, such a description is inadequate. Even when using more descriptors like deeper/higher than normal, onset delays, pitch breaks, breathy, click, tight, etc, more information is needed.

There are 2 fundamental ways to more precisely convey the characteristics of how a raspy voice sounds and to document change (better/worse) over time.

Method #1 - Perceptual Tests

Developed by Dr. Robert Bastian, I personal prefer this method as it is more intuitive and replicable by anybody including the patient.

1) Maximum Phonation Time (MPT) - How many seconds can a single note be sustained for with a single breath? This test provides a rough measure of lung capacity and how "breathy" a voice is. The more breathy a voice is, the lower the MPT.
2) Pitch Range - What is the lowest and highest note a person can say/sing (I use a piano keyboard). Provides information on how much vocal cord swelling and length is present (the more swollen the vocal cords are, the deeper the pitch just like a violin string). I also typically like the patient to glide up and down from their lowest and highest note as it provides some additional information on neurological/muscular control of their voice depending on how smoothly it is performed.
3) Swell Tests - Essentially, the test involves singing a song (I use Happy Birthday) very quietly an octave higher than your normal pitch. If onset delays or pitch breaks are heard, does suggest the presence of a small bump (nodule, cyst, polyp, etc) on the vocal cords.

One can also add documentation of yell, cough, throat-clearing, and speaking voice.

Method #2 - Objective Tests

This type of testing can only be performed with the help of instruments and provides "numbers" that can be documented. It is more difficult to "hear" the voice looking at just these numbers, but does provide a more rigorous way to actually "measure" the voice quality. There are now even iPhone apps that can obtain such data.

The basic measures include:
1) Shimmer - Measures how much variation in loudness is present. Think of a volume knob being turned up and down slightly. Normal is less than 3%.
2) Jitter - Measures how much variation in pitch is present. Think of going up and down on the equalizer slightly. Normal is less than 1%.
3) MPT is also measured.
4) Fundamental frequency (f0) - Measure of how high/low a person's voice sounds (pitch).

One can go crazy and also add intensity, glottal noise, ratio, tremor, spectrum, EGG-pitch, EGG-intensity, EGG-jitter, EGG-shimmer, EGG-noise, CQ, CQ perturbation, CI, CI perturbation, opening rate, etc.

Regardless of the method, with this type of information, the actual degree and characterization of the vocal quality can be measured, documented, and tracked over time. Also, when communicating with other health professionals, such measures provide for an efficient and understandable way to describe a patent's voice with a colleague.

Of course, from the patent's perspective, they "just want to sound better," but this is how professionals do it.

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New Video on Tongue Tie Release Procedure

Tongue tie is a common problem whereby a flap of tissue anchors the tongue tip to the bottom of the mouth. With tongue tie, it is impossible for a patient to stick the tongue straight out (licking an ice cream is impossible) and may potentially lead to problems with feeding in a newborn baby, speech articulation in a young school-age child, and french kissing in teenagers and older.

Due to the frequency at which tongue tie release is performed and the questions parents often have about how this procedure is exactly performed, a video has been created to show the steps on a newborn baby. With the gracious permission of one mom... check out this video.

Tongue tie may not be the only problem that may cause breast-feeding difficulty in an infant. Upper lip tie and posterior tongue tie may also be present.

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How the Voice Anatomically Reverberates to Produce Speech

Came across this old school animation showing how sound produced in the voicebox reverberates in the upper airway, mouth, and nasal cavity to produce speech that everybody else hears.

To watch what it looks like from the inside, check this video out.

Source:

FFFFound! 5/23/11

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Dr. Chang Quoted in the Wall Street Journal

The Wall Street Journal on 3/15/13 published a story on how voice therapy and vocal surgery can dramatically improve a person's vocal quality... seemingly taking years away from how you sound.

In this story, Dr. Chang was quoted a few times and even included a patient he has treated successfully with voice surgery to restore his voice.

In regards to how aging can create muscle atrophy and bowing resulting in:

"It creates a breathy, raspy voice," says Christopher Y. Chang, an otolaryngologist at Fauquier Ear, Nose & Throat Consultants in Warrenton, Va.

Later in the WSJ article, surgical intervention is discussed and introduced Mr. James Driver, a Warrenton, VA jewelry repair storeowner who Dr. Chang treated:

"In the procedure, called injection augmentation of the vocal folds, a doctor threads an endoscope through the patient's nose or mouth into the throat, then injects a tiny amount of collagen, fat, hyaluronic acid or a gel filler into the vocal cords to plump them up. The substances usually last three to six months. If the procedure works, a doctor may recommend inserting silicon or Gore-Tex implants to fatten the cords permanently.

In 2011, James Driver was felled by an episode of temporary paralysis that left one of his vocal cords frozen. The 57-year-old owner of a Virginia jewelry-repair business worked with a therapist and did throat exercises on his own, but he could only manage a whisper. "You had to be right next to him with your ear to his mouth" to hear him, says his wife, Erin.

The couple sought out Dr. Chang, who recommended an injection. The day after the procedure, Mr. Driver was speaking at near regular volume. A year later, he's still going strong, though he hears his own voice as being slightly raspier than it used to be. "It made a huge difference," Mrs. Driver says."

 Read the full article here.

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Hearing and Understanding ONE Voice Among Many Sounds

Have you ever wondered how is it that a normal hearing human being can hear and understand one person talking in an environment where there are many other people talking just as loudly be it a restaurant, conference, county fair, etc?

How is it that you can hear and understand one particular person over another, even if they are both talking equally loud?

Researchers are just beginning to understand how a human does it... Before explaining, lets use an analogy.

In the past, I used the analogy of an old antenna based radio to explain how human hearing works... A given antenna radio has a volume knob that one can adjust up or down (as would occur with a hearing aid) as well as antenna reception which allows one to get a clear signal vs one full of static.

The ear is like the volume knob and the brain is the antenna... As such, if the reception is bad and there's a lot of background static, a person will have a hard time understanding what is being said on the radio... regardless of whether the volume knob is turned up all the way or not.

Similarly, if the brain is not filtering out the background noise to isolate the sound or person you want to hear and understand, you will have a hard time understanding what is being said.

While the ear indiscriminately hears everything, I've always just stated "the brain" acts to filter out the background noise you don't want to hear, but nobody really understood how, until recently...

Researchers in New York determined that there are different regions of the brain that perform this sound filtration that is completely separate from the auditory cortex (part of the brain that "hears" sounds transmitted from the ear).

Furthermore, the brain areas responding only to the selected voice constantly fine-tunes the reception to allow further improvement in comprehension over time... just like fiddling with an antenna to get as clear a signal on a radio station.

If the brain is not able to properly focus and filter the sound, the individual will have a hard time understanding conversation in a noisy environment, regardless of whether the person has normal hearing or not (for example, in patients with ADHD).

Of course, if hearing loss is also present along with an unfocused brain, it just makes it that much harder (for example, in the elderly who not only have hearing loss, but also decrease in brain function as well).

On the opposite extreme are people who make their living focusing on a specific sound among many sounds and have much greater ease in understanding people talking in a noisy environment. Take professional musicians in an orchestra who excel at hearing a single instrument during a Beethoven orchestral performance.

Source:
Hear That? In A Din Of Voices, Our Brains Can Tune Into One. NPR 3/6/13

Reference:
Mechanisms Underlying Selective Neuronal Tracking of Attended Speech at a “Cocktail Party”. Neuron, Volume 77, Issue 5, 980-991, 6 March 2013

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How Much Tongue Can Be Removed Without Affecting Function?

Unfortunately, whether through trauma or cancer concerns, parts of the tongue may be removed. When a part of the tongue is removed, the principal concern patients have is whether speech and swallow will be affected.

The answer to this question depends on 3 main factors.

• What orientation is the tongue removed?

• How much is removed?

• Will nerve function be preserved? The nerve is what makes the tongue move (specifically cranial nerve 12 called the hypoglossal nerve)

Regardless of how much or little of the tongue gets removed, if nerve function is lost, speech and swallow will be affected. As such, when tongue resection is performed, extreme care is taken to preserve nerve function and not to accidentally cut the hypoglossal nerve unless absolutely necessary (the nerve is invaded by cancer). As an FYI, this nerve is about 1.75cm off to the side of the tongue's midline.

When tongue removal is performed on the SIDE of the tongue, up to 1/3 of it can be removed without significant speech or swallow deficits ASSUMING nerve function remains intact and tongue tip is left alone. If more than 1/3 is removed, some degree of reconstruction will be required involving taking skin and muscle from the forearm to fill the space lost to the tongue resection (procedure is called radial forearm free flap).

If the tongue tip is removed, far less can be lost before it will start to affect speech. Why? Because the tongue tip is used to help articulate words. How much can be removed before it starts to affect speech depends on the tongue length and shape. Swallow is typically unaffected.

Typically tongue tip removal occurs through trauma when it may get bitten off during a seizure or bitten off by another individual as occurred to this man whose tongue tip was bitten off by his girlfriend when he tried to kiss her. [link]

Side of the tongue removal usually occurs through surgical excision due to cancer concerns.

Sleep Apnea

As an aside, there is another type of tongue removal procedure used to address obstructive sleep apnea where the central back part of the tongue is removed. This procedure is performed when the tongue is large and causes obstruction while a person is sleeping. If properly performed, no speech or swallow deficits will occur.

Read more about this procedure here.

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What to Do and Care After Vocal Cord Surgery

When surgery is performed on the vocal cords, there are some very specific after-care that is required to allow for optimal healing. In order to understand the "why" such post-operative care is required, one must first understand how the vocal cords normally work. If you already know, just skip down to the bottom.

The vocal cords are arranged in the shape of a "V". When breathing, the vocal cords are open to allow air to pass through and down into the windpipe. When talking, the vocal cords come together and vibrate. Click here to watch a video.

When surgery is performed on the vocal cords, one is actually cutting into the actual organ that allows one to talk and make other noises.


As such, the care required after vocal cord surgery requires the elimination of any activity that may lead to damage to the surgery site and allow proper and safe healing.

I should mention that the following instructions are our opinion. Other laryngologists may have different after-care instructions.

Strict Voice Rest! 

This means absolutely no talking and whispering. Such activities cause the vocal cords to come together and "bang" against the surgery site. I even instruct patients to avoid even mouthing words as it causes the brain to "think" you are talking even if you are not. Essentially, the lips should always remain closed except when eating/drinking.

The analogy would be if you have surgery done on the heel of your foot, you should not walk or put any weight on the heel, otherwise risk improper healing.

Strict voice rest typically lasts for 1-2 weeks after surgery.

No Coughing or Throat-Clearing

Just as with talking, coughing and throat-clearing also causes the vocal cords to come together and should be avoided if at all possible. Narcotic strength cough-suppressants (ie, hycodan) are often prescribed to help suppress the urge to cough.

Take Reflux Medications

Reflux medications should be taken both before and after surgery to prevent any possibility of acid damage to the surgery site. Such medications should be taken EVEN IF you do not have any symptoms of acid reflux. I typically recommend patients to start such medications one week before surgery and to continue for as long as 3 months after surgery.

Voice Therapy

Voice therapy is recommended before surgery so that patients will understand what and how they are supposed to talk once cleared to do so after surgery. It's much easier to answer questions and practice proper talking technique before surgery rather than after surgery when you are on strict voice rest!

The rationale for voice therapy is to prevent continued phono-trauma to a freshly healing surgery site on the vocal cord. Often, if improper talking technique persists after surgery, the surgery site becomes damaged again or heals with abnormal scar tissue leading to the possibility of needing surgery again.

Voice therapy minimizes the likelihood of needing repeat vocal cord surgery in the future!

Restricted Voice Rest

Once the period of strict voice rest ends, the patient is slowly allowed to talk under voice therapy guidance. From this point forward over the next 4-6 months, the patient is under restricted voice rest.

Restricted voice rest is a fairly broad phrase, but essentially means to:

• NEVER abuse the voice (ie, yelling, screaming, loud talking, etc)
• Talk only when you must (ie, no social talking)

This period of restricted voice rest is important because it allows time for the new vocal cord tissue that has developed to not only heal, but also strengthen. Abusing the voice may tear the freshly healed surgery site which must be avoided at all costs!

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Speech Impediment to Great Singing on American Idol

During January 2013 auditions of Season 12 of American Idol, there was Lazaro Arbos who has a terrible stutter when he talks, but sings beautifully. A week later, we encountered Micah Johnson who also suffers from a speech impediment, but rather than a stutter, it was due to "nerve damage" sustained during a tonsillectomy. (Watch videos below)

With stuttering, the problem mainly lies at the brain level. The brain coordinates how a person uses all of their throat muscles to create speech. Talking and language is mainly a LEFT-brain activity (or more precisely, the dominant hemisphere). Singing is mainly a RIGHT-brain activity and as such, uses different pathways than talking. It's also the same reason why patients who have suffered from a stroke may not be able to talk at all, but can sing their words out.

Now, in the case for Micah Johnson, it is reported that his speech impediment was due to "nerve damage" from tonsil removal surgery. As such, his speech impediment is NOT at the brain level (also known as central), but peripheral. Peripheral nerve injury is much more difficult to correct and requires extensive practice (speech therapy) in order to create brand new pathways at the brain level to help it "adapt" and compensate for the loss of function from the nerve injury. The analogy would be walking with a limp to compensate for a leg injury.

However, in Micah's case, it is a bit difficult to explain why he talks with an impediment, but sings wonderfully. It is not a matter of activating previously established brain pathways as what happens with stuttering.

With a tonsillectomy, there is a mouth gag placed to move the tongue out of the way. Typically, this surgery takes about 15 minutes to perform on average. Per Micah, his tonsillectomy took 90 minutes or almost 6 times longer than normal.

I hypothesize that the mouth gag over that time duration slowly crushed the nerve innervating the tongue (cranial nerve 12) causing it to not move as well leading to his speech difficulties. This complication is EXTREMELY rare and if it occurs, almost always temporary. This situation is analogous to a "dead" arm when sleeping on it for too long... but recovering normal function after a few minutes.

Unfortunately in Micah's case, it seems to never have recovered fully.

The puzzling issue for me is how is it that he is able to sing, but not talk well? Peripheral nerve injuries would affect ANY activity involving the affected muscle. For example, if the nerve to a leg muscle is cut, that muscle will not work well whether running or walking. The ability to sing, but not talk well due to a peripheral nerve injury is akin to stating that one can only limp when walking, but can run fantastic.

Anyone have any ideas what may be going on with Micah's amazing singing?

Just as an FYI, another rare complication of tonsillectomy that may lead to speech problems is velopharyngeal insufficiency leading to a hyper-nasal sounding speech. In this situation, there is no nerve damage present. Rather, it is an anatomic problem whereby the soft palate does not 'lift" completely to close off the nasal passage from the mouth. This problem can be surgically fixed.

In any case, best of luck to both men!

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Julie Andrews and Her "Botched Throat Surgery"

It has already been well-publicized that the former singing sensation Julie Andrews underwent some type of throat surgery in 1997 after which she never regained her phenomenal 4-octave voice thus relegating her to more conventional roles of being an actress without the singing. This "botched throat surgery" per Julie Andrews lead to a lawsuit that was ultimately settled.

It is unknown precisely what type of (presumed) vocal cord pathology was present as well as what type of surgical approach was used to try and fix it. In a recent interview, she stated:

"The operation that I had left me without a voice and without a certain piece of my vocal chords"

However, given her aggressive and active singing career prior to surgery, she probably had vocal cord nodules, a benign growth that occurs due to vocal overuse, a situation not uncommon with professional singers.

Vocal cord nodules are most always due to excessive voice use leading to "callous" formation on the vocal cord lining, much like shoveling dirt will eventually lead to callous formation on the hands.

Traditional standard of care management of vocal cord nodules is voice therapy and avoidance of any activities leading to voice abuse (screaming, yelling, etc). However, resolution of nodules with such behavior focused treatment takes months. However, although it takes a while for the nodules to resolve with this treatment method, they typically do not come back.

For patients who are more "impatient" for results (not unusual with professional singers whose livelihoods depend on singing), there are more aggressive ways to address vocal cord nodules with possible resolution within weeks. However, the caveat is if the underlying voice behavior that led to nodule formation in first place is not addressed, the vocal cord nodule WILL recur after initial resolution/improvement. Furthermore, as with any more invasive treatments to obtain a "quick fix", scar formation may occur leading to permanent voice changes, usually for the worse which obviously happened with Julie Andrews.

What are some of these more invasive treatments beyond voice therapy? To reiterate, these procedures also have a high risk of recurrence if underlying abusive voice behavior that led to the nodule formation in first place is not first addressed.

• Surgical excision can be performed, but can lead to permanent scar formation during the healing process that can lead to persistent irreversible hoarseness.

• Botox injection can also be pursued which causes a "partial" vocal cord paralysis preventing the repetitive trauma in the region of the vocal cord nodule.

• Steroid injection to the vocal cord nodule(s) can possibly resolve or reduce the nodule resulting in improved vocal quality within weeks. Such local injection technique has mainly been performed in the treatment of spasmodic dysphonia (botox injection), vocal cord granulomas, and vocal cord paralysis. Watch a video how a "local injection" to the vocal cord can be performed (video shows injection of vocal cord granuloma rather than nodule, but overall approach is identical).

Read more about vocal cord nodules here.

Source:
Julie Andrews' Voice Isn't Coming Back, But She's Not Staying Silent. Huffington Post 12/5/12

PUBLIC LIVES; Julie Andrews Sues Throat Surgeon. NYT 12/15/99

Julie Andrews Settles Lawsuit Against Doctors. ABC News 9/7/12

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New Video on Treatment of Hyper-Nasal Speech by Injection

Our office has created a new video that we have uploaded that shows how hyper-nasal speech can be corrected via injection of filler agents under endoscopic guidance.

Keep in mind that this procedure ONLY works with small velopharyngeal insufficiency.

Hyper-nasal speech occurs when there is too much nasal airflow during speech as opposed to hypo-nasal speech (ie, nasal obstruction) which occurs when there is little or no nasal airflow during speech. In either case, the voice sounds "nasal".

Check out the video here.

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Nasal Sounding Speech

There are actually TWO different flavors of nasal sounding speech.

HYPO-nasal speech is due to reduced or no nasal airflow and HYPER-nasal speech due to too much nasal airflow.

HYPO-nasal speech is by far the most common cause of nasal-sounding speech. It is similar to how a person would sound if they pinched their nose shut while talking. As such, ANY anatomic nasal obstruction would by definition lead to such hypo-nasal speech. Treatment, obviously, is to remove this anatomic nasal obstruction whatever it may be either with medications or surgery. Examples of hypo-nasal speech causes include:

• Adenoid Hypertrophy (Very Common)
• Turbinate Hypertrophy (Common)
• Significant Deviated Septum (Uncommon)
• Nasal Polyps (Uncommon)
• Allergies (Common)
• Infection (upper respiratory illness and/or bacterial infections) (Common)
• Rarely, genetic conditions like cystic fibrosis and immotile ciliary syndrome
• Rarely, anatomic conditions such as choanal atresia
• Rarely, a sino-nasal tumor
  

HYPER-nasal speech itself has several different flavors, but the key concept is the presence of an opening between the mouth and nose when it should be sealed shut during speech. Normally, complete closure should occur with certain sounds like /s/, /sh/, /b/, and /p/. Such sounds are called plosives and sibilants. This link provides a cartoon animation of how each sound in the English language is produced from an anatomical standpoint.

Now what are some of the causes of HYPER-nasal speech? Causes can be divided broadly into either anatomic and functional variants.

Anatomic HYPER-nasal speech include:

• Cleft Palate
• Palate Fistula
• Submucus Cleft

Functional HYPER-nasal speech include:

• Velopharyngeal insufficiency without anatomic cause. Velopharyngeal insufficiency or VPI occurs when the soft palate does not seal against the back of the mouth during appropriate speech sounds.
• Poor articulation (person is not correctly pronouncing words)

Treatment of HYPER-nasal speech may include speech therapy and surgery depending on the cause.

Given the subtleties involved in differentiating the different causes of nasal speech, workup typically involves not only just looking in the nose or mouth, but also performing a nasal endoscopic examination.

Below is a video showing a young child undergoing just such an endoscopic exam. Here are some other videos containing audio of abnormal endoscopic exams.

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Miss America, SLP-CCC

Miss Wisconsin Laura Kaeppeler won the Miss America title for 2012 this past weekend.

This news co-mingled with all the other news of the day, except for one key fact that caught my attention...

Miss Kaeppelar majored in music and vocal performance and plans to obtain a Master's degree in speech and language pathology (SLP).

A voice major with a Master's in SLP is a rare combination that is in great demand in the world of laryngology where singers with vocal injury are common. A SLP who specializes in the injured voice is rare. A SLP who knows and understands opera intimately is exceedingly rare.

The vast majority of SLP are specialists in speech production... not voice.

Why is this distinction important?

Speech is basically sound that is produced by a person after modification by the lips, teeth, tongue, palate, and throat of a person. As such, speech issues are related to problems stemming from these anatomical parts.

Voice is basically the sound that is produced by the voicebox. Basically, it is the noisemaker upon which the sound produced is modified to ultimately produce speech. In another words, "voice" is created prior to "speech". Voice problems are limited to anatomical or functional abnormalities of the voicebox resulting in a raspy/hoarse/breathy sounding voice. Such problems include vocal cord nodules, vocal cord polyps, spasmodic dysphonia, paralyzed vocal cords, etc.

Depending on whether a patient is suffering from a speech problem or a voice problem determines what type of SLP is appropriate.

Miss Kaeppelar would (hopefully) be classified into a special (and rare) category of SLP who specializes not just in voice therapy, but voice therapy for singers with an injured voice.

Read more about voice versus speech therapy here.


Source:
Miss America confronted family pain with pageant. FoxNews 1/14/12

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Steroid Injection to Eliminate Vocal Cord Nodules

Vocal cord nodules are most always due to excessive voice use leading to "callous" formation on the vocal cord lining, much like shoveling dirt will eventually lead to callous formation on the hands.

Traditional standard of care management of vocal cord nodules is voice therapy and avoidance of any activities leading to voice abuse (screaming, yelling, etc). However, resolution of nodules with such behavior focused treatment takes months. However, although it takes a while for the nodules to resolve with this treatment method, they typically do not come back.

For patients who are more "impatient" for results, there are more aggressive ways to address vocal cord nodules with resolution within weeks. However, the caveat is if the underlying voice behavior that led to nodule formation in first place is not addressed, the vocal cord nodule WILL recur after initial resolution/improvement.

Recently, there have been several studies that have shown that steroid injection directly into vocal cord nodule can resolve or reduce the nodule resulting in improved vocal quality within weeks. Such local injection technique has mainly been performed in the treatment of spasmodic dysphonia (botox injection), vocal cord granulomas, and vocal cord paralysis.

In the most recent study published Oct 2011, researchers have found that in a group of 80 patients, 44% had complete resolution of the nodule and another 49% had improvement within 4 weeks after injection of the nodule with Kenalog 40. 8% had recurrence of the nodule after initial improvement due to persisting in a high voice-use occupation. 4 patients suffered vocal cord atrophy and 2 patients developed a white plaque that resolved spontaneously 1-2 months after injection.

Watch a video how a "local injection" to the vocal cord can be performed (video shows injection of vocal cord granuloma rather than nodule, but overall approach is identical).

Beyond voice therapy and steroid injections, there are other ways of dealing with vocal cord nodules, but also have a high risk of recurrence if underlying abusive voice behavior that led to the nodule formation in first place is not first addressed.

• Surgical excision can be performed, but can lead to permanent scar formation during the healing process that can lead to persistent hoarseness.

• Botox injection can also be pursued which causes a "partial" vocal cord paralysis preventing the repetitive trauma in the region of the vocal cord nodule.

Read more about vocal cord nodules here.

References:
Local steroid injection via the cricothyroid membrane in patients with a vocal nodule. Arch Otolaryngol Head Neck Surg. 2011;137(10):1011-1016. doi:10.1001/archoto.2011.168

Steroid injection to vocal nodules using fiberoptic laryngeal surgery under topical anesthesia. Eur Arch Otorhinoloaryngol. 2004. 261(9):489-492.

Laryngeal steroid injection. Curr Opin Otolarngol Head Neck Surg. 2009. 17(6): 424-426.

Office Steroid Injections of the Larynx. Laryngoscope. 2006. 116(10):1735-1739.

Percutaneous corticosteroid injection for vocal fold polyp. Arch Otolaryngol Head Neck Surg. 2009. 135(8):776-780.

Intracordal injection of dexamethasone. Pract Otorhinoloaryngol (Basel). 1964. 57(3):496-500.

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Posterior Tongue Tie

An ordinary garden-variety tongue tie (also known as ankyloglossia) is an uncommon condition whereby the tongue is anchored to the floor of the mouth preventing the tongue tip from moving freely.

Patients with tongue tie have greater difficulty with:

• feeding if infant
• speech if school-age child
• french kissing if young adult

Treatment is tongue tie release which can be done at any time if difficulties arise. In infants and young adults, this procedure can be done in the office under local anesthesia only. In school age kids, it typically requires sedation given lack of cooperation with keeping the mouth open and tongue still.

Posterior Tongue Tie

Though tongue tie is uncommon, there is an even more uncommon (or perhaps less recognized) subtype called submucus tongue tie or posterior tongue tie.

This condition is when the tongue tie is hidden UNDER the mucus lining of the tongue/mouth. You can't see this type of tongue tie, but you can feel it if you run the finger underneath the tongue from side to side where the tongue tie would be. One would feel a tissue band (speed-bump sensation with finger sweep) where the tongue tie would be.

Treatment is a bit more complicated than a regular tongue tie release in that the mucus lining has to be incised in order to expose the tongue tie prior to release. Once the tongue tie is released, the incision is sutured closed.

Read more about this condition and treatment here.

Another less known condition is upper lip tie which may also cause breast-feeding difficulty.

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