Department of Otolaryngology

Speech Pathology

• Pediatric Speech-Language-Communication Evaluation Therapy
• Laryngectomy Rehabilitation
• Closed Head Injury
• Voice Clinic
• Swallowing Difficulty (Dysphagia)
• Stroke Rehabilitation
• Spasmodic Dysphonia

Pediatric Speech-Language-Communication Evaluation and Therapy
The optimal period for intervention with speech-language-communication delayed/disordered children is during early childhood. It is has been assumed that the earlier that speech therapy begins, the better the outcome should be. Certain diagnoses are known to cause speech and language disorders and are manifested at birth or in early infancy. Some include Down syndrome, maternal rubella, cleft palate, and cerebral palsy. On the other hand, children's communicative status may be the first indicator in the diagnosis of neurodevelopmental disorders. Children who may receive the diagnosis of autism, apraxia, dysarthria, or language learning disabled will exhibit deficits in communication often before other abnormalities are noted.

The pediatrician is most likely to be the first professional to come in contact with and evaluate children with speech-language-communication problems. Thus, the pediatrician plays an important role in the early identification of these children. Two strategies for the detection of possible problems include high-risk registers at birth and the use of developmental scales checked during pediatric visits for routine examination and immunization.

The Speech-Language clinic in the Physician Office Center of the Robert C. Byrd Health Sciences Center provides comprehensive speech-language and communication evaluations. Therapy on an outpatient basis is also available. The goal of our clinic is to provide appropriate intervention strategies for each child and to ensure collaboration with and among other entities who participate in a child's remediation efforts. Therapy is typically scheduled for 30-60 minute sessions two times a week. Speech-Language Pathologists (SLP's) provide home activities for the parents to carry out with their child. SLP's also collaborate with teachers or other caregivers in order to encourage optimum intervention profiles for each child. Parents or caregivers accompany their child to each therapy session and observe each therapy session via two-way mirrors. Following each session SLP's discuss specific goals to be addressed in other settings.

Laryngectomy Rehabilitation
The American Cancer Society estimates that as many as 12,500 new cases of laryngeal cancer are diagnosed every year. Approximately one half of the patients diagnosed with cancer of the larynx (voice box) will undergo a laryngectomy, that is, the removal of the larynx, in order to give the individual the best chance of being cured.

The patient undergoing a laryngectomy is seen by a speech/language pathologist prior to his/her surgery for a pre-operative counseling session. Family members are strongly encouraged to attend as well. The goal of this session is to review the primary anatomical changes that will occur during surgery, discuss postoperative communication options, and answer any questions the patient or family member may have. The electrolarynx is introduced and the patient is given the opportunity to practice using it. The electrolarynx is a hand held device that mimics the vibrations of the vocal cords, and when held against the neck allows the person to produce sounds and ultimately speech. The tracheoesophageal puncture procedure is reviewed as a possible means of communication following surgery.

Speech therapy is initiated several days after surgery. The patient is provided with his/her own electrolarynx and instructed in its use. Further education is provided regarding care of the stoma and in the overall changes in body function, such as, smelling, tasting, swallowing, and airway protection.

A tracheoesophageal puncture (TEP) is a surgical technique that enables a person to direct air from the lungs up through the esophagus, again enabling that person to produce sound and ultimately speech by taking advantage of tissue vibration in the throat. A TEP can be done at the time of the cancer surgery or several months after surgery. Patient candidacy is determined by the doctor and speech pathologist. Once the puncture site is healed, the speech pathologist fits the appropriate size prosthetic device, works with the patient to achieve good voicing, and trains the patient to take care of the device.

Closed Head Injury
Communication skills often change after a person suffers a closed head injury. Common difficulties that can occur include slurred speech, difficulty formulating thoughts or thinking of specific words, impulsivity, difficulty attending or concentrating, poor memory, and difficulty making safe and appropriate judgement calls. The Speech Clinic at the Physician Office Center offers speech/language therapy to patients during their hospitalization and also as out-patients after discharge from the hospital. Therapy schedules are varied, according to individual needs. The goals of therapy are always geared towards functional activities, and family members are always included to encourage use of newly learned skills into everyday situations.

Voice Clinic
We use our voices every day and take it for granted that it is our means of communication. However, voicing is a highly coordinated activity of the laryngeal muscles that requires anatomic and neurophysiologic integrity. Typical complaints about voices include a "hoarse or raspy voice" or "a change in vocal quality." Common diagnoses include vocal cord nodules, polyps, contact ulcers, vocal cord paralysis, papillomas, or cancer of the larynx. Numerous conditions and diseases can affect our voice; some of them severe enough to cause a person to have to quit a job or withdraw from society.

A thorough diagnostic evaluation is extremely important in reaching a diagnosis and developing an appropriate treatment plan. The Voice Center at West Virginia University offers a voice clinic two times per month. An appointment involves an evaluation by an otolaryngologist, followed by a voice evaluation by the speech/language pathologist.

Otolaryngology has state of the art equipment necessary for a thorough examination. Patients are evaluated using laryngeal videostroboscopy, a technique that allows us to see subtle movements of the vocal cords that cannot be seen with the naked eye and also magnifies the picture so that we are able to examine the vocal cords in greater detail. Small lesions that can be missed using traditional laryngoscopy can be identified with videostroboscopy. The examination is videotaped so that it can be reviewed later by the physician and the patient. This provides important visual feedback for patients, greatly enhancing their understanding of their vocal cord problem and often facilitates better compliance with the plan of treatment.

The voice evaluation by the speech/language pathologist involves an in-depth case history, touching on all areas that affect vocal production (e.g., medical history, voice complaint, vocal use). The SpeechViewer Computer system is utilized to obtain objective information about pitch, intensity, and vocal quality. Different behaviors that can affect voice production are reviewed and suggestions specific to each patient's needs are made. Ongoing therapy is sometimes recommended and is scheduled at times convenient for the patient.

Together, the patient, the otolaryngologist, and the speech/language pathologist, work to obtain the best possible vocal quality.

Swallowing Difficulty (Dysphagia)
Eating is so automatic that most people take it for granted. Normal swallowing is a very fast process; it takes less than two seconds for food or liquid to move from the mouth through the pharynx and into the esophagus. Swallowing involves a complex sequence of nerve, muscle, and central nervous system interactions.

Difficulty in swallowing (dysphagia) for adults is primarily the result of mechanical disorders, muscle disorders, or nerve disorders. Mechanical disorders are most often associated with surgery for cancer. Muscle and nerve disorders may include myasthenia gravis, muscular dystrophy, multiple sclerosis, amyotrophic lateral sclerosis, Parkinson's disease, stroke, and head injury.

Dysphagia also occurs in children and infants. There is an increasing percentage of this population who are confronted with significant medical problems. Some of the most striking problems are related to swallowing and feeding.

Spasmodic Dysphonia
Spasmodic dysphonia is a voice disorder characterized by a very strained and strangled sounding voice. The abrupt initiation and termination of voicing makes people with this disorder very difficult to understand and communication is awkward. Once thought to be a hysterical condition, the exact cause is still not fully understood, however, it is now widely recognized as having an organic basis.

The treatment of spasmodic dysphonia has changed significantly throughout the years. Psychiatric counseling and voice therapy were initially prescribed, but were rarely helpful. Severing of the recurrent laryngeal nerve was the next treatment offered, however, improvement of the voice was temporary. The nerve often regenerated and repeat surgery was not an option. The most current and effective treatment is the injection of botulinum toxin into the vocal cords. The toxin binds to presynaptic terminals and blocks the secretion of acetylcholine, weakening vocal cord movement. This provides temporary relief for patients and diminishes the strained and strangled sounding vocal quality. This is not a permanent cure, and most patients require repeated injections every three to six months.

West Virginia University is presently the only facility in the area offering this treatment. Under local anesthesia, the needle is guided into position with the aid of electromyographic (EMG) monitoring by a neurologist; the injection is completed by the otolaryngologist. Speech therapy is provided to discuss typical responses from the injection and also to counsel the patient regarding vocal quality between injections. The clinics are usually held once per month, depending on patient need. Follow-up phone calls are made to monitor progress.