Khalid H Al Malki, MD, PhD

1. Done By: 428 C2 KhalidHAlMalki,MD,PhD Consultant,AssociateProfessor Phoniatrics(Voice,CommunicationandSwallowingDisorders) Head,CommunicationandSwallowingDisordersUnit(CSDU) ENTDepartment KingAbdulazizUniversityHospital KingSaudUniversity,Riyadh,SaudiArabia. Head,CommunicationandSwallowingDivision(CSDD) ORL/HNSDepartment RiyadhMilitaryHospital,Riyadh,SaudiArabia http://faculty.ksu.edu.sa/kmalky/default.aspx

2. KhalidHAlMalki,MD,PhD

5. InternetSite http://vas.ksu.edu.sa

6. Communication andSwallowing Disorders KhalidHAlMalki,MD,PhD

7. Aimofthispresentation: IntroduceCommunicationandSwallowing Disordersandhowtheyaremanagedgenerally, andNOTtocoveralldisordersindetails. KhalidHAlMalki,MD,PhD

8. CommunicationDisorders Communicationdifficultieshaveanimpacton thefollowingaspects: Academic (misarticualtion, stuttering) Social, Psychological, Employment (part of qulaification) Professional (singer, actor, teacher, doctor, imam Of masjd, public speaker Financial: very expensive to treat these disorders Ex: 50,000 sr are the fees per year for on child who has autism Familyrelations. KhalidHAlMalki,MD,PhD

9. Things he mention in intro • امراض التخاطب: الكلاو, الصوت, النطق A child was delayed in language development; is it important to treat him? And if it is who treats him? • When does a baby says his first word? • Is stuttering (تلعثم )a psychiatric problem? • Does nasality الخنةindicate a problem and how many types are there (hypo-hyper nasality). (م,ن)الخنة الطبيعية

10. Voice comes from the vocal fold. • How many times do we swallow a day?

11. ﺐﻁﺎﺨﺘﻟﺍ ﺽﺍﺮﻣﺃ ﺕﻻﺎﺠﻣ Communication Disorders ﻊﻠﺒﻟﺍﺽﺍﺮﻣﺃ SwallowingDisorders ﻡﻼﻜﻟﺍﺽﺍﺮﻣﺃ SpeechDisorders ﺔﻐﻠﻟﺍﺽﺍﺮﻣﺃ LanguageDisorders ﺕﻮﺼﻟﺍﺽﺍﺮﻣﺃ VoiceDisorders KhalidHAlMalki,MD,PhD

12. Language (لغة): I inderstand – comprehend- I say a sentencce Asymbolicarbitrarysystemrelatingsoundsto meaning. Has two types: receptive (understands the question), expressive (ask him to say a sentence and answer in a fluent way). It has more central effect that speech) معنةالكلام Speech (كلام) Aneuro-muscularprocesswherebylanguageis It uttered. includes the coordination of respiration,phonation,articulation,resonation andprosody. Pronounce the letters right (r, s) no nasality, stuttering, no misarticulation. النطق KhalidHAlMalki,MD,PhD

13. Voice Theresultofvibrationofthetruevocalfolds usingtheexpiredair. Remember not cord Swallowing Theprocessofsuccessfulpassageoffoodand drinksfromthemouththroughpharynxand esophagusintothestomach. It is a process in which food bullos, passes normally from the mouth until it by passes The lower esophageal sphincter. KhalidHAlMalki,MD,PhD

14. WhoismanagingCommunication andSwallowingDisorders? Twoschools: • Phoniatricians(MD’s). • Manage better from a medical backgound • Can do endoscopy without supervision • Give medical diagnosis • Give medication • Can be a surgeon 2.Speech-Languagepathologists. KhalidHAlMalki,MD,PhD

15. WhatisPhoniatrics? A medical specialty that deals with communicationandswallowingdisorders. ItstemsmainlyfromORL(ENT),especially whendealingwithVOICEdisorders. UnionoftheEuropeanPhoniatricians(UEP) www.phoniatrics-uep.org KhalidHAlMalki,MD,PhD

16. Phoniatrics(cont.) In 1931, ”Phoniatrics“ was officially recognized and acknowledged as an independentmedicalspecialtyofitsownin Sweden. In1992,”Phoniatrics&Pedaudiology“ becameanewself-standingmedicaldiscipline inGermany. UnionoftheEuropeanPhoniatricians(UEP) www.phoniatrics-uep.org KhalidHAlMalki,MD,PhD

17. Phoniatrics(cont.) AmedicalsubspecialtyofENT(Otorhinolaryngology) asapprovedby: -SaudiCommissionForHealthSpecialties. -ENTDepartment,KingSaudUniversity. -SaudiSocietyofOtorhinolaryngology. KhalidHAlMalki,MD,PhD

18. ThePhoniatrician: -DealswiththepatientfromaMEDICAL prospective. -Canperformendoscopieswithoutany limitations. -Canprescribemedicationswhenneeded. -Canperformsurgeriesifinterestedandtrained. KhalidHAlMalki,MD,PhD

19. IALP KhalidHAlMalki,MD,PhD

20. recognized IsPhoniatrics internationally? TheInternationalAssociationofLogopedicsand Phoniatrics(IALP)isaglobalorganizationwhich promotestheimprovementofcareforpeoplewith communicationdisorders. www.ialp.info KhalidHAlMalki,MD,PhD

21. IALP: IALPrepresentsaprofessionalbodyof: 125.000membersinhumancommunication 56affiliatednationalsocietiesfrom 38countriesand overthreehundredindividualmembers. IALPhasinformativestatuswithUNESCO, UNICEF,WHO,…. KhalidHAlMalki,MD,PhD

22. Communication Disorders Swallowing Disorders Voice Disorders Speech Disorders Language Disorders DLD (Children) Dysphasia (Adults) Organic Non-organic MAPLs Stuttering Cluttering Misarticulation Hypernasality Dysarthria KhalidHAlMalki,MD,PhD

23. Language Disorders KhalidHAlMalki,MD,PhD

24. I.LanguageDisorders: [1]DelayedLanguageDevelopment(DLD): is the most Common language disorder in children In adults its called dyphasia; misarticualtion, stuttering, Cluttering, hypernasality, Definition of DLD: Delayorfailuretoacquirelanguagematched withage. KhalidHAlMalki,MD,PhD

25. Prerequisites of normal language development: 1.Normalbrainfunction. 2.Intactsensorychannels(egauditory). 3.Normalpsyche. 4.Stimulatingenvironment. KhalidHAlMalki,MD,PhD

26. Causes of DLD: A)Brain damage: -Diffusebraindamage(MR). -Braindamagedmotorlyhandicappedchild(CP). -Minimalbraindamage(ADHD). B)Sensory deprivation: Hearingimpairment. C)Psychiatric disorders: -Autism. -Childhoodschizophrenia. D)Non - stimulating environment. E)Idiopathic. KhalidHAlMalki,MD,PhD

27. Diagnosis of the Cause of DLD: I. Historytaking. II.Physicalexamination. III.Investigations: -Psychometry(IQ). -Audiometry. DLD Sheet KhalidHAlMalki,MD,PhD

28. Management of DLD: Earlydetection. Providingthesuitableaid(HAorCI). Familycounseling. Languagetherapy. KhalidHAlMalki,MD,PhD

29. I.Languagedisorders: [2]Dysphasia: Definition: Languagedeteriorationafteritsfulldevelopment duetobraininsult:infarction,hemorrhage, atrophy,etc KhalidHAlMalki,MD,PhD

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31. Types of dysphasia: 1.Expressive. 2.Receptive. 3.Mixedpredominantlyexpressive. 4.Mixedpredominantlyreceptive. 5.Global. KhalidHAlMalki,MD,PhD

32. Diagnosis of dysphasia: I. Historytaking. II.Physicalexamination:…,neurological exam. III.Investigations: -CT/MRIbrain. -Dysphasiatest. -Psychometry(IQ). -Audiometry. Dysphasia Sheet KhalidHAlMalki,MD,PhD

33. Management of dysphasia: Individualized: Managementofthecause. Physicalrehabilitation(Physiotherapy). Familycounseling. Languagetherapy. Alternativeandaugmentativecommunication. KhalidHAlMalki,MD,PhD

34. Voice Disorders KhalidHAlMalki,MD,PhD

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39. Prerequisites of “normal” voice production: 1.Normalrangeofmovementofvocalfolds. 2.Normalmobilityofmucosaondeeplayers. 3.Optimalcoaptationofvocalfolds’edges. 4.Optimalmotorforce. 5.Optimalpulmonarysupport. 6.Optimaltimingbetweenvocalfoldclosureand pulmonaryexhalation. 7.Optimaltuningofvocalfoldmusculature(int.& ext.). KhalidHAlMalki,MD,PhD

40. Definition of dysphonia: -“Difficultyinphonation”. -“Changeofvoicefromhis/herhabitual”. -“Hoarseness”=roughness&harshnessofvoice. KhalidHAlMalki,MD,PhD

41. Etiological classification of dysphonia: • Organic Causes • Ex: paralysis of one • Vocal fold II. Non-Organic Causes Habitual Psychogenic Everything appears normal even endoscopy no pathology no foreign body III.MinimalAssociated PathologicalLesions (MAPLs) IV.AccompanimentofNeuro-psychiatricAilments KhalidHAlMalki,MD,PhD

42. An example of inorganic causes: Person has no problem starting to talk but at the end of the day she / he is exhausted and gets tried from talking with no underlying pathology. This is called phonasthenia (voice fatigue)

43. III.Voicedisorders: A)Organicvoicedisorders: . . . . . . . Congenital. Inflammatory. Traumatic. Neurological. Neoplastic. Hormonal. Statuspost-laryngectomy. KhalidHAlMalki,MD,PhD

44. To produce a word, sentence, letter, etc we need energy (our energy source is breathing/air) because any voice needs power. Air enters into the lung then trachea then to larynx particularly between vocal fold (which adduct in phonation) and little air passes through the adducted folds to produce phonation. • Sound to be clarified passes through resonators (over resonance is hypernasality; nasal contamination of sound) • Finally the resonating sound passes through articulators (lip, soft, hard palate, tongue, lips) which modulates the primary laryngeal sound. Dr. said pharynx and lung but I thinks these are resonators correct me if I am wrong. • All these functions are controlled by centers

45. Function of the larynx • Respiration • Phonation not the most important function of the larynx. Close the vocal folds • Protection • Valsalva the vocal folds must close in order to do effort as a result of an increase in the intrathoracic pressure • Swallowing also closes the vocal folds or else will result in aspiration • The most important functions of the larynx are both respiration and protection

46. Sulcusvocalis KhalidHAlMalki,MD,PhD

47. Laryngealcarcinoma Phonation Respiration KhalidHAlMalki,MD,PhD

48. Approach to patient with dysphonia: • History and examination • Investigation • Endoscopy • Laryngeal stroboscopy is a special method used to visualize the vocal folds vibration. It uses a synchronized, flashing light passed through a flexible or rigid telescope. The flashes of light from the stroboscope are synchronized to the vocal fold vibration at a slightly slower speed, allowing the examiner to observe vocal fold vibration during sound production in what appears to be slow motion. A telescope is inserted per oral/ per-nasal. Per-oral is better and per-nasal is used in a hyper-gagging child). A microphone is put at the neck of the patient and a recording is made. Voice = folds have to adduct. Air builds up below subglottis increases subglottic pressure. Lower lip opens then upper lip opens by bernoulli’s effect. The movement of vocal folds is normally not seen by the naked eye because the frequency is high (female= 220 cycles/sec; male=110). Frequency of flash = frequency of vibration; allowing us to visualize the movement in slow motion (mucosal wave is important in phonation). • High speed camera no sampling (takes a picture of everything and shows it in true slow motion) 2000 frames/sec. • Acoustic analysis “say Ahh” and gives a certain analysis

49. Leftvocalfoldparalysis * * Phonation Respiration KhalidHAlMalki,MD,PhD

50. III.Voicedisorders: B)Non-organicvoicedisorders: i.Habitual: 1.Hyperfunctionalchildhooddysphonia. 2.Incompletemutation. 3.Phonasthenia(Voicefatigue). 4.Hyperfunctionaldysphonia. 5.Hypofunctionaldysphonia. 6.Ventriculardysphonia. KhalidHAlMalki,MD,PhD