Nil per os except medications order in the dysphagic patient

OBJECTIVES

To demonstrate why the 'nil per os except medications' order is contraindicated prior to dysphagia testing and to recommend ways to prevent aspiration of medications in the dysphagic population.

METHODS

A 71-year-old male deemed at-risk for aspiration due to coughing when drinking thin liquids was made nil per os except medications and referred for dysphagia testing. Swallowing was analyzed objectively with trans-nasal fiberoptic endoscopic evaluation of swallowing.

RESULTS

Aspiration on the initial 5 cc puree bolus swallow trial elicited a cough reflex. A 325 mg, 1 cm diameter, enteric coated aspirin pill emerged from the trachea, progressed through the glottis and remained transiently in the laryngeal vestibule before lodging, along with pudding residue, in a mucosal fold of the left vallecula. Neither volitional coughing nor single 5 cc water bolus swallows dislodged the pill. Otolaryngology was called and removed the pill trans-orally under direct visualization with a Kelly clamp. The pill maintained both its enteric coating and integrity for a total of 7.5 h after being aspirated.

CONCLUSION

The nil per os except medications order is contraindicated in the dysphagic population. When aspiration is suspected, nil per os including medications is recommended until dysphagia testing determines what form of medication can be swallowed safely.

Safe initiation of oral diets in hospitalized patients based on passing a 3-ounce (90 cc) water swallow challenge protocol

BACKGROUND

Safe and timely oral alimentation is crucial for optimum patient care.

OBJECTIVE

To determine the short-term success of recommending specific oral diets, including drinking thin liquids, to acute care hospitalized patients at risk for dysphagia based on passing a 3-ounce water swallow challenge protocol.

DESIGN

Prospective single group consecutively referred case series.

SETTING

Large, urban, tertiary care, teaching hospital.

PARTICIPANTS

1000 hospitalized patients.

INTERVENTION

3-ounce (90 cc) water swallow challenge protocol.

MEASUREMENTS

Specific diet recommendations and volume (in cc) of liquid ingested at the next day's meal 12-24 h after passing a 3-ounce challenge protocol were accessed electronically from oral intake information entered on each participant's daily care logs. Eating and drinking success, clinically evident aspiration events and compliance with ordering the recommended diet were recorded. Care providers were blinded to the study's purpose.

RESULTS

Of 1000 patients, 907 met the inclusion criteria of stable medical, surgical or neurological conditions 12-24 h after passing a 3-ounce water swallow challenge protocol. All 907 were both eating and drinking thin liquids successfully and without overt signs of dysphagia. Median volume of liquid ingested was 340 cc [interquartile range (IQR), 240-460]. Specific diet recommendations were followed with 100% accuracy.

CONCLUSION

A 3-ounce water swallow challenge protocol successfully identified patients who can be safely advanced to an oral diet without subsequent identification of overt signs of aspiration within 12-24 h of testing. Importantly, when a clinical 3-ounce challenge protocol administered by a trained provider is passed, specific diet recommendations, including drinking thin liquids, can be made safely and without the need for additional instrumental dysphagia testing.

Effect of tracheotomy tube occlusion on upper esophageal sphincter and pharyngeal pressures in aspirating and nonaspirating patients

The biomechanics of the pharyngeal swallow in patients with a tracheotomy tube were investigated with manometry. Upper esophageal sphincter (UES) and pharyngeal pressure recordings were made with and without occlusion of the tracheotomy tube. Criteria for selection were ability to tolerate tracheotomy tube occlusion for both 5 minutes prior to and during the first manometric analysis, absence of surgery to the upper aerodigestive tract other than tracheotomy, and no history of oropharyngeal cancer or stroke. Aspiration was determined objectively by fiberoptic endoscopic evaluation of swallowing (FEES) immediately prior to manometric recording. Eleven adult individuals with tracheotomy participated; 7 swallowed successfully and 4 exhibited aspiration on FEES. The results indicated no significant effect of tracheotomy tube occlusion on UES or pharngeal pressures in either aspirating or nonaspirating patients. It was concluded that the biomechanics of the swallow as determined by UES and pharyngeal manometric pressure measurements were not changed significantly by tracheotomy tube occlusion in aspirating or nonaspirating patients. These results support previous observations that subjects either aspirated or swallowed successfully regardless of tracheotomy tube occlusion status.

Use of arterial oxygen saturation, heart rate, and blood pressure as indirect objective physiologic markers to predict aspiration

If an indirect bedside variable can reliably predict whether an objective instrumental dysphagia evaluation is needed, time and money can be saved without compromising patient care. To date, the search for a reliable indirect subjective marker of aspiration has not been successful. However, research on indirect objective markers of aspiration is alluring. The purpose of the present study was to investigate changes, if any, in the physiologic parameters of arterial oxygen saturation (SpO(2)), heart rate, and blood pressure during simultaneous objective confirmation of aspiration status with Fiberoptic Endoscopic Evaluation of Swallowing (FEES). Sixty adult subjects were divided into 4 groups of 15. Group 1 did not require supplemental oxygen and did not aspirate. Group 2 did not require supplemental oxygen and exhibited aspiration. Group 3 required supplemental oxygen and did not aspirate. Group 4 required supplemental oxygen and exhibited aspiration. Simultaneous SpO(2), heart rate, and blood pressure measurements were collected at 1-min intervals, i.e., pre-FEES baseline for 5 min; during FEES; and post-FEES for 5 min. Results indicated no significant differences in SpO(2) levels based on aspiration status or oxygen requirements for any of the 4 groups. A consistent pattern of higher heart rate values during FEES and continuing for 5 min post-FEES was observed for all 4 groups. A consistent pattern of higher blood pressure values during FEES and then lower blood pressure values post-FEES was observed for all 4 groups. It was concluded that the use of changes in SpO(2), heart rate, or blood pressure values as indirect objective markers of aspiration was not supported.

Fiberoptic endoscopic evaluation of swallowing in the pediatric population

OBJECTIVE

To investigate the diagnostic and rehabilitative usefulness of routine fiberoptic endoscopic evaluation of swallowing (FEES) in the pediatric population.

STUDY DESIGN

Prospective, consecutive, blinded.

PATIENTS AND METHODS

Thirty pediatric inpatients from a large, urban, tertiary care teaching hospital participated. Their ages ranged from 11 days to 20 years (mean, 10 years and 4 months). In a random fashion, seven subjects were assessed with both videofluoroscopic evaluation of swallowing (VFES) and FEES and 23 subjects were assessed solely with FEES. Diagnosis of dysphagia was determined by spillage, residue, laryngeal penetration, and aspiration. Rehabilitative strategies, e.g., positioning and modification of bolus consistencies, were based on diagnostic findings.

RESULTS

There was 100% agreement between the blinded diagnostic results and implementation of rehabilitative strategies for subjects randomly assigned to receive both VFES and FEES and for subjects who received solely FEES. Of the 23 subjects assessed solely with FEES, 13 of 23 (57%) exhibited normal swallowing and 10 of 23 (43%) exhibited dysphagia. The feeding recommendation for 4 of 10 subjects with dysphagia (40%) was for a non-oral diet because of aspiration. FEES allowed for specific feeding recommendations (i.e., bolus consistency modifications, positioning, and feeding strategies) to reduce aspiration risk in 6 of 10 subjects with dysphagia (60%).

CONCLUSION

FEES can be used routinely to diagnose and treat pediatric dysphagia in the acute care setting.

Investigation of the causal relationship between tracheotomy and aspiration in the acute care setting

OBJECTIVE

To investigate the causal relationship, if any, between tracheotomy and incidence of aspiration in the acute care setting.

STUDY DESIGN

Prospective, consecutive.

PATIENTS AND METHODS

Twenty adult patients evaluated between February 1997 and October 1999 participated. Criteria for inclusion were a dysphagia evaluation before tracheotomy, subsequent tracheotomy and placement of a tracheotomy tube, and then a repeat dysphagia evaluation after tracheotomy prior to decannulation. This permitted the causal relationship between tracheotomy and incidence of aspiration to be investigated. Differences between duration of tracheotomy placement and age were analyzed with the Student t test and for non-parametric nominal data the chi2 test was applied.

RESULTS

No causal relationship between tracheotomy and aspiration was exhibited, as 19 of 20 (95%) subjects exhibited the same aspiration status before and after tracheotomy. All 12 (100%) subjects who aspirated before tracheotomy also aspirated after tracheotomy and 7 of 8 (88%) subjects who did not aspirate before tracheotomy also did not aspirate after tracheotomy (P > .05). In addition, no significant differences were observed between aspiration status and days since tracheotomy or age (P > .05).

CONCLUSION

In the acute care setting, no causal relationship between tracheotomy and aspiration status was exhibited.

Fiberoptic endoscopic evaluation of swallowing in patients with acute traumatic brain injury

Dysphagia and aspiration in intensive care unit patients with acute traumatic brain injury (TBI) is a frequent and potentially life-threatening problem. Any diagnostic technique used with this population, therefore, must be able to be performed in a timely and efficient manner while providing objective information on the nature of the swallowing problem. The purpose of the present study was to investigate the utility of using the fiberoptic endoscopic evaluation of swallowing (FEES) technique to diagnosis pharyngeal stage dysphagia and determine aspiration status in patients who presented with acute TBI. A total of 47 subjects were assessed with FEES. Thirty of 47 (64%) subjects swallowed successfully and were able to take an oral diet: 2 of 30 (7%) thickened liquids and purée consistencies, 8 of 30 (27%) a soft diet, and 20 of 30 (67%) a regular diet. Seventeen of 47 (36%) subjects exhibited pharyngeal stage dysphagia with aspiration and were not permitted an oral diet based on objective results provided by FEES. Of the 17 subjects who aspirated, 9 of 17 (53%) exhibited silent aspiration. Younger subjects (mean age 34 years, 3 months) aspirated significantly less often than older subjects (mean age 51 years, 8 months). No significant age difference was observed for gender or between overt and silent aspirators. It was concluded that FEES is an objective and sensitive tool that can be used successfully to diagnose pharyngeal stage dysphagia, determine aspiration status, and make recommendations for oral or nonoral feeding in patients with acute TBI.

Effect of a one-way tracheotomy speaking valve on the incidence of aspiration in previously aspirating patients with tracheotomy

The purpose of the present study was to investigate the incidence of aspiration in previously aspirating patients with tracheotomy after use of a one-way tracheotomy tube speaking valve. Twenty consecutive inpatients from the acute care setting of a large urban tertiary care teaching hospital were included. All subjects had objective documentation of aspiration by a fiberoptic endoscopic evaluation of swallowing prior to placement of a one-way tracheotomy speaking valve, from 2 to 7 days of valve use with intelligible speech production, and no surgery to the upper aerodigestive tract except tracheotomy. Results indicated that incidence of aspiration was not affected by use of a one-way tracheotomy speaking valve. These results are in agreement with previous observations that subjects either aspirated or swallowed successfully regardless of tracheotomy tube occlusion status. Also, no significant differences were found between aspiration status and time since tracheotomy, time off ventilator, or duration of valve use. It was concluded that use of a one-way speaking valve provided mostly nondeglutitive benefits and should not be considered to promote successful swallowing for patients with tracheotomy in the acute care setting.

Serial fiberoptic endoscopic swallowing evaluations in the management of patients with dysphagia

OBJECTIVE

To determine whether serial fiberoptic endoscopic evaluation of swallowing (FEES) can be used successfully and efficiently in deciding to change a patient's feeding status from nonoral (NPO) to oral (PO) with no adverse health outcome.

DESIGN

A prospective, consecutive, cohort study.

SETTING

Inpatient population of a tertiary-care university teaching hospital.

SUBJECTS

Thirty-two adults were recruited from a cohort of 400 consecutive subjects who participated in a previous dysphagia study.

INTERVENTION

Serial FEES was performed 3 to 6 times in each subject to detect objectively pharyngeal phase dysphagia, aspiration, and aspiration risk and to provide information for recommendations regarding oral feeding status and therapeutic intervention. The number of FEES was based on the subject's medical status, evidence of dysphagia, and clinical judgement.

MAIN OUTCOME MEASURES

Identification of pharyngeal phase dysphagia, aspiration, and aspiration risk, and recommendations for initial feeding status, when to resume oral feeding, and what bolus consistencies to use for optimal swallowing success.

RESULTS

In all subjects, serial FEES detected pharyngeal phase dysphagia, aspiration, and aspiration risk and enabled determination of initial feeding status (NPO or PO), when to resume successful oral feeding, and what bolus consistencies to use for optimal swallowing success. Specifically, 15 of 32 (47%) subjects received FEES 3 to 5 times within only 6 to 22 days. Timely serial FEES allowed 22 of 32 (69%) subjects to resume an oral diet as early and safely as possible.

CONCLUSIONS

No subject who resumed an oral diet based on results of FEES developed an aspiration pneumonia. Serial FEES, therefore, enabled feeding status to be successful and efficiently changed from NPO to PO with no adverse health outcome. FEES was an efficient procedure with regard to appointment scheduling, transportation, patient issues, and personnel requirements.

Fiberoptic endoscopic documentation of the high incidence of aspiration following extubation in critically ill trauma patients

The purpose of this study was to investigate the incidence of aspiration following extubation in critically ill trauma patients. This prospective pilot study included 20 consecutive trauma patients who required orotracheal intubation for at least 48 hours. All subjects underwent a bedside transnasal fiberoptic endoscopic evaluation of swallowing at 24 +/- 2 hr after extubation to determine objectively aspiration status. Aspiration was defined as the entry of a blue dyed material into the airway below the level of the true vocal folds, with silent aspiration occurring in the absence of any external behavioral signs such as coughing or choking. Aspiration was identified in 9 of 20 (45%) subjects and 4 of these 9 (44%) were silent aspirators. Therefore, silent aspiration occurred in 20% of the study population. Eight of the 9 (89%) aspirating subjects resumed an oral diet from 2-10 days (mean, 5 days) following extubation. All subjects had no evidence of pulmonary complications. It was concluded that trauma patients after orotracheal intubation and prolonged mechanical ventilation have an increased risk of aspiration. An objective assessment of dysphagia to identify aspiration may reduce the likelihood of pulmonary complications after extubation.

Tracheotomy tube occlusion status and aspiration in early postsurgical head and neck cancer patients

The purpose of the present study was to investigate tracheotomy tube occlusion status and prevalence of aspiration utilizing videofluoroscopy. A prospective study was done of 16 consecutive, early, postsurgical head and neck cancer patients with tracheotomy. Selection criteria included the ability to tolerate tracheotomy tube occlusion prior to and during the modified barium swallow procedure, oral and/or pharyngeal surgical resection, no history of neurological disease or stroke, and medical clearance to begin oral feeding. There was 100% agreement among the independent reviewers on ratings of the presence or absence of aspiration. It was found that occlusion status of the tracheotomy tube did not influence the prevalence of aspiration in the immediate postoperative period. No trends were observed when comparing bolus consistency, type of tracheotomy tube, or presence/absence of a nasogastric tube and the ratings of aspiration.

Fiberoptic endoscopic evaluation of dysphagia to identify silent aspiration

The traditional bedside dysphagia evaluation has not been able to identify silent aspiration because the pharyngeal phase of swallowing could not be objectively assessed. To date, only videofluoroscopy has been used to detect silent aspiration. This investigation assessed the aspiration status of 400 consecutive, at risk subjects by fiberoptic endoscopic evaluation of swallowing (FEES). Our study demonstrated that 175 of 400 (44%) subjects were without aspiration, 115 of 400 (29%) exhibited aspiration with a cough reflex, and 110 of 400 (28%) aspirated silently. No significant differences were observed for age or gender and aspiration status. The FEES, done at bedside, avoids irradiation exposure, is repeatable as often as necessary, uses regular food, can be videotaped for review, and is a patient-friendly method of identifying silent aspiration.

A prospective, double-blind, randomized study on the use of a topical anesthetic, vasoconstrictor, and placebo during transnasal flexible fiberoptic endoscopy

The purpose of the present study was to compare patient comfort levels following administration of a topical anesthetic, vasoconstrictor, placebo, or nothing to the nasal mucosa prior to flexible fiberoptic transnasal endoscopy. Using a prospective, double-blind, randomized design, 152 consecutive patients were randomly assigned to receive a topical anesthetic (N = 54), vasoconstrictor (N = 50), or placebo (N = 48). No significant differences were found among the three variables. An additional 50 consecutive patients had endoscopy performed without administration of any substance to the nares, and no significant differences were found among the four variables (N = 202). It was concluded that speech-language pathologists can perform independent and comfortable transnasal endoscopy without administration of any substance to the nasal mucosa. Flexible fiberoptic endoscopy, however, should be performed by experienced clinicians with care taken to examine visually the patency of both nares for ease and comfort of scope insertion.

Voice restoration after laryngectomy: experience with the Blom-Singer extended-wear indwelling tracheoesophageal voice prosthesis

BACKGROUND

The Blom-Singer tracheoesophageal voice prosthesis has undergone continuous design modifications during the last 18 years to make it more effective, anatomically compatible, and easier to use. This evolution continues with the recent introduction of an indwelling-style voice prosthesis intended for use by individuals who are unable or disinclined to use a self-removable-style voice prosthesis. The a priori self-lifespan goal of the indwelling prosthesis was 180 days.

METHODS

The present investigation describes the experience of 81 consecutive participants who used a total of 206 indwelling voice prosthesis. Selection criteria included total laryngectomy and either primary (n = 35) or secondary (n = 46) tracheoesophageal puncture. All participants had external-beam radiotherapy either pre- or postlaryngectomy. Specifically, lifespan of the prosthesis, the effects and clinical management of fungal colonization, and participant satisfaction with this style prosthesis were studied.

RESULTS

A prosthesis use rate of 90% was observed. Group 1 prostheses (without fungal colonization and without Nystatin therapy) exhibited a lifespan significantly longer than did group 2 prostheses (with fungal colonization and prior to Nystatin therapy) (sample mean [mean] = 185.6 days versus 80.6 days; p < .05). Group 3 prostheses (following Nystatin therapy) also exhibited a lifespan significantly longer than that of group 2 prostheses (mean = 156.1 days versus 80.6 days; p < .05). Lifespans of group 1 and group 3 prostheses were not significantly different (p < .05).

CONCLUSIONS

The extended-wear, indwelling voice prosthesis achieved its a priori lifespan goal of 180 days (6 months) with almost uniform patient preference and without risk of increased complications. When fungal colonization was present. Nystatin therapy significantly prolonged prosthesis lifespan.

Adult onset of stuttering as a presenting sign in a parkinsonian-like syndrome: a case report

Stuttering onset in adulthood is rare. With no prior history of stuttering or demonstrable neurological insult, diagnosis is often that of a conversion reaction. Stuttering as the first sign of a parkinsonian-like syndrome in extrapyramidal disease has only been reported once in the previous 30 years (Koller, 1983). The present case study differs from and builds upon the case reports in the literature, and describes a 29-year-old white male who began stuttering purportedly secondary to psychological stress. The fluency evaluation revealed severe stuttering characterized by multiple repetitions and/or blocks, with 20 or more repetitions per word routinely noted during both conversational speech and oral reading. No starters or secondary stuttering characteristics, no specific word fears or avoidances, and no situational fears were exhibited. The subsequent neurological examination found resting tremor in hands and legs, lingual fasciculations, gait imbalance, and numbness and tingling of the hands and feet, all of which were progressive in nature. Rehabilitation initially focused on fluency therapy, but then included psychiatric therapy, and finally medical intervention. Fluency and psychiatric therapies were unsuccessful in eliminating stuttering. Following a diagnosis of parkinsonian-like syndrome, medical intervention with carbidopa-levodopa resulted in dramatic improvement of motor, sensory, and fluency symptoms. It is important to consider extrapyramidal disease as an etiological factor in patients with adult onset of stuttering.

Gag reflex and dysphagia

BACKGROUND

The gag reflex is a protective response that prevents foreign objects or noxious material from entering the pharynx, larynx, or trachea; it is not elicited during a normal swallow. Although no data have been reported to support a relationship between the gag reflex and dysphagia, the gag reflex is nevertheless routinely assessed during the bedside dysphagia evaluation. The purpose of the present study was to investigate whether absence of a gag reflex is a predictor of dysphagia.

METHOD

Fourteen consecutive adult subjects referred for a bedside dysphagia evaluation because they were considered to be at increased risk for aspiration, specifically due to absence of a gag reflex, were investigated. In addition, the gag reflex was assessed in 69 normal adult volunteers.

RESULTS

Although all subjects were referred for bedside dysphagia evaluations specifically because they had no gag reflex, 86% (12/14) were nevertheless able to eat at least a puree diet. In addition, 86% (12/14) of subjects with no gag reflex had normal velar movement, reinforcing the physiologic differences between velar functioning during phonation and the gag reflex. The gag reflex, traditionally considered part of the bedside dysphagia evaluation, was absent in 13% (9/69) of nondysphagic subjects, raising further doubts regarding its clinical relevancy.

CONCLUSION

The absence of a gag reflex does not appear to be a predictor of dysphagia.

Effect of occlusion of a tracheotomy tube on aspiration

The purpose of the present study was to investigate the effect of occlusion of a tracheotomy tube on aspiration utilizing fluoroscopy. Twenty consecutive tracheotomized patients referred for a modified barium swallow were included. Selection criteria were ability to tolerate tracheotomy tube occlusion during the modified barium swallow procedure, no surgery of the upper aerodigestive tract except tracheotomy, and no history of oropharyngeal cancer or stroke. There was 100% agreement among 3 independent reviewers on ratings of the presence or absence of aspiration. It was found that the occlusion status of the tracheotomy tube did not influence the prevalence of aspiration. Nine of 10 (90%) subjects who exhibited aspiration were over 65 years of age (mean = 72 years 2 months). No trends were observed for bolus consistency, type of tracheotomy tube, or presence/absence of a nasogastric tube and ratings of aspiration.

Incidence, timing, and importance of tracheoesophageal prosthesis resizing for successful tracheoesophageal speech production

The Blom-Singer method of tracheoesophageal (TE) speech restoration is a proven alternative to esophageal and electrolaryngeal speech in patients with total laryngectomy. This retrospective study was undertaken to determine the incidence and timing of TE prosthesis resizing, amount of change in prosthesis length, etiologies associated with resizing, and importance of long-term professional follow-up for maintenance of successful TE speech production. Participants were 26 individuals with total laryngectomy and secondary TE puncture. Results indicated that all 18 participants available for long-term follow-up required TE prosthesis resizing, and multiple resizings were required in 87% of the routinely followed participants. In 14 participants the prostheses were resized shorter (sample mean [mean] = -0.7 cm); in 3, longer (mean = +0.5 cm); and in 1, from a duckbill to a low-pressure prosthesis of the same size. The mean number of days from initial measurement and fitting to first prosthesis resizing was 26. The importance of collaboration between the speech-language pathologist and otolaryngologist and need for long-term follow-up for successful maintenance of TE speech are stressed. Cost containment of rehabilitation services using the indwelling TE prosthesis is demonstrated.

Perceptual rankings of speech quality produced with one-way tracheostomy speaking valves

Perceptual speech quality rankings, mechanical functioning, and maintenance of respiration as measured by oxygen saturation were determined for four different one-way tracheostomy speaking valves. Results indicated significant differences in speech quality rankings, with the Montgomery and Passy-Muir valves ranked significantly better than the Kistner and Olympic valves, and the Olympic valve ranked significantly better than the Kistner valve. The Passy-Muir valve was identified with the best speech quality most often by both listeners and subjects, and exhibited the fewest clinically relevant mechanical problems. Maintenance of respiration was not affected by use of any of the valves studied.

Long-term changes in vocal quality following Isshiki thyroplasty type I

Long-term changes in vocal quality, pre-Isshiki thyroplasty type I and up to 4 years 4 months post-thyroplasty, were determined in a group of five subjects exhibiting unilateral vocal fold paralysis. Thyroplasty type I medializes the paralyzed fold by using a Silastic implant for external compression of the paralyzed vocal fold. No periphonosurgical or post-phonosurgical complications were noted. Longitudinal evaluation resulted in significantly higher vocal fundamental frequency, significant moderation of habitual vocal intensity, and significantly longer maximum phonation time. The thyroplasty group exhibited significantly more breath groups than control subjects both prethyroplasty and post-thyroplasty; within the thyroplasty group, a reduction in breath groups was exhibited prethyroplasty as compared to post-thyroplasty. The long-term positive changes observed in fundamental frequency, intensity, maximum phonation time, and breath groups were attributed to medialization of the paralyzed vocal fold.

Speaking fundamental frequency, intensity, and rate of adventitiously profoundly hearing-impaired adult women

No objective group data on speaking fundamental frequency (F0), intensity, or rate have been reported on the speech of adventitiously profoundly hearing-impaired adult women. Results of the present study showed that F0 was significantly higher, intensity significantly greater, and speaking rate significantly slower for 12 adventitiously profoundly hearing-impaired adult women than for 20 normal-hearing control subjects of the same sex and approximate age. Based on these objective data, aural rehabilitation is recommended for the improvement and monitoring of speaking F0, intensity, and rate abnormalities in the adventitiously profoundly hearing impaired.

Prognostic indicators for successful use of "talking" tracheostomy tubes

7 prognostic indicators for successful verbal communication for 40 patients who use “talking” tracheostomy tubes and who are cognitively intact and ventilator dependent are presented.

Verbal communication for the ventilator-dependent patient: voice intensity with the Portex "Talk" tracheostomy tube

A patient's ability to communicate is critical to overall medical care, psychological functioning, and social interactions. Voice intensity levels produced by 20 patients with Portex "Talk" cuffed speaking tracheostomy tubes were investigated at three different airflow rates. Results indicated that audible and intelligible speech was produced with significantly greater intensity (P less than .001) over ambient room noise at 5 l/minute, 10 l/minute, and 15 l/minute of airflow. Also, significantly greater voice intensity (P less than .001) was noted as airflow increased from 5 l/minute to 10 l/minute and from 10 l/minute to 15 l/minute. The criteria, rationale, and importance of using a speaking tracheostomy tube with cognitively intact ventilator-dependent patients are discussed. The specific advantages and disadvantages of the Portex "Talk" tracheostomy tube are delineated. A case study is included.

Longitudinal voice quality changes following Isshiki thyroplasty type I: the Yale experience

Longitudinal voice quality changes following Isshiki thyroplasty type I were investigated in a group of 13 patients exhibiting unilateral vocal fold paralysis. Thyroplasty type I medializes the paralyzed fold by using a Silastic implant for external lateral compression of the abducted fold. No perioperative complications were experienced. We observed significantly higher voice fundamental frequency, significantly louder voice intensity, and significantly longer maximum phonation time, both immediately following phonosurgery and up to 3 months postoperatively. Surgical refinements of thyroplasty type I are described.

A perceptual evaluation of the speech of adventitiously deaf adult males

The present study investigated the effects of adventitious deafness on perceptual judgments of segmental and suprasegmental speech production skills. Subjects were 25 adventitiously deaf and 10 normal-hearing adult male speakers. Twelve subjects were classified as aidable profound (AP) and 13 subjects were classified as unaidable profound (UP). Each subject was judged by 15 listeners, first on seven speech and voice variables and, second, on whether they were adventitiously deaf or normal-hearing and, if adventitiously deaf, if speech rehabilitation was warranted. Both the AP and UP adventitiously deaf subjects were judged significantly different from each other and from normal-hearing subjects on all seven variables. They were, in hierarchical order: intonation, pitch, rate, nasality, vowel duration, articulation, and intensity. Aural rehabilitation was judged to be warranted in 49% of the speakers identified as being adventitiously deaf, specifically 26% of the AP speakers and 74% of the UP speakers. This finding indicates that auditory information is a necessary component for maintaining accurate speech and voice production abilities following onset of profound hearing loss after the acquisition of an adult phonological system.

Longitudinal effects of single-channel cochlear implantation on voice quality

No studies have reported longitudinal group data on the voice characteristics of adult participants with adventitious profound sensorineural hearing loss before and after single-channel cochlear implantation. This study investigated voice fundamental frequency, intensity, and speaking duration preimplantation and longitudinally 1-day, 6-months, and 1-year poststimulation. Results revealed only fundamental frequency 1-day poststimulation to be significantly different from preimplantation. Trends for all three variables, i.e., lowered Fo, reduced intensity, and shortened speaking duration (a faster rate), however, moved toward the measures that typify normal-hearing speakers.

Tracheogastric puncture for vocal rehabilitation following total pharyngolaryngoesophagectomy

Speech rehabilitation postpharyngolaryngoesophagectomy has not received significant emphasis. We describe our experience with five patients who underwent a delayed tracheogastric puncture (TGP) after pharyngogastric anastomosis. When compared to patients who had undergone tracheoesophageal puncture (TEP) after laryngectomy, speech intelligibility and fluency were adequate for conversational speech, but voice quality was characterized by lower pitch, reduced intensity, slower rate, and a "wet" quality. There were no complications related to the TGP. TGP is a safe and often useful procedure for voice and speech restoration in patients who have undergone total pharyngolaryngoesophagectomy and pharyngogastric anastomosis.

Voice intensity of patients using a Communi-Trach I cuffed speaking tracheostomy tube

Voice intensity levels produced by 20 patients with cuffed speaking tracheostomy tubes (Communi-Trach I) at three different airflow rates were investigated. Results indicated that audible and intelligible speech was produced with significantly greater intensity over ambient room noise at 5 l/minute, 10 l/minute, and 15 l/minute of airflow. Criteria for use, common causes of malfunctioning, and rehabilitation techniques necessary for the successful use of cuffed speaking tracheostomy tubes are discussed.

Stomal complications and airflow line problems of the Communi-Trach I cuffed talking tracheotomy tube

There have been no reports of stomal complications and airflow line problems associated with a cuffed talking tracheotomy tube. However, the results of this study showed that stomal complications, in the form of pressure necrosis and wound extension, and problems with airflow line kinking occurred with a 40% and 80% frequency, respectively. Solutions to both difficulties are discussed.

Speech segment duration measurements in adult speakers with repaired cleft palate and hypernasality

Consonant closure duration, vowel duration preceding word-final stop consonants, and total VCVC utterance duration were measured in order to investigate if normal durations in these variables were exhibited in subjects with cleft palate and hypernasality. The data revealed no significant differences among three adult subject groups (noncleft, repaired cleft with mild hypernasality, and repaired cleft with severe hypernasality) on any of the duration measurements investigated, suggesting that speech timing for these features were not significantly altered by the presence of the nasal air leak. Speakers in the two hypernasal groups, however, showed smaller differences between vowel durations in voiced and voiceless stop environments than did speakers without cleft palate. There were significant differences among groups in durational cues between vowel types and between voicing features of stop consonants, both of which were in agreement with previous research.

Standardization of four videotaped tests of speechreading ranging in task difficulty

Repeated measures are needed to assess speechreading ability of prospective cochlear implant candidates and to follow their progress over the course of treatment. To perform such measures, high quality color videotaped versions of four speechreading tests were constructed using a male and a female speaker. Materials were selected to provide gradations in task difficulty ranging from responses to questions with the topic known, to verbatim repetition, to abstraction of information from a spoken paragraph in order to answer questions. The tests were: (1) NAL/West Haven modification; (2) Iowa-Keaster, Forms A and B; (3) CID Everyday Sentences; and (4) Gold Rush Paragraph. The tapes were standardized by presentation to young adult normal subjects. Results indicated that a range of performance could be measured by using the present tests as a battery, although the anticipated ranking of tests was not obtained.

Immediate effects of cochlear implantation on voice quality

Seminal quantitative group acoustic data are presented on voice quality changes following electrical stimulation (ES) of the auditory nerve via a single-channel cochlear implant (CI). It was found that the fundamental frequency (Fo) of our patients was significantly lower after the first day of ES, while intensity and speaking duration were not significantly different from pre-CI values. These results suggest that the CI provides enough frequency information less than 300 Hz to permit immediate and independent alterations in voice Fo towards normal-hearing speakers values. Our findings also indicate that intensity and speaking duration require additional time before differences found become significant. Longitudinal data are still needed to determine if Fo continues to lower and if intensity and/or speaking duration change significantly to approximate values observed in normal-hearing individuals.

Speaking fundamental frequency of postlingually profoundly deaf adult men

We investigated the speaking fundamental frequency (F0) of 21 postlingually profoundly sensorineurally deaf men. Results indicated that speaking F0 was significantly higher for the deaf group than for normal-hearing, age-matched men. Neither duration of profound deafness nor hearing aid usage affected speaking F0 values significantly. The findings of the present study provide a baseline for determining the effects of rehabilitation.

Voice intensity of prospective cochlear implant candidates and normal hearing adult males

Voice intensity in 19 prospective cochlear implant candidates, all adventitiously profoundly sensorineurally deaf adult males, was investigated. For the first time with objective data, it was shown that such deaf subjects spoke with significantly increased voice intensity and with greater intensity fluctuations than normal hearing male speakers. Neither length of time of profound deafness nor history of hearing aid use significantly affected voice intensity. Based on quantitative data, rehabilitation of voice intensity problems in the adventitiously deaf is indicated.

Vibrotactile stimulation for the adventitiously deaf: an alternative to cochlear implantation

Acoustic correlates of the prosodic features identifying English contrastive stress, ie, fundamental frequency (Fo), duration and intensity, and listener perceptions were investigated in a profoundly adventitiously deaf subject (D) pre/postvibrotactile stimulation, and in an age-peer normally-hearing person as a control (N). Stimuli were a group of general American English words in which a change of function from noun to verb was associated with a shift of stress from initial to final syllable, eg, CON'test vs conTEST'. Prior to vibrotactile stimulation, D was unable to produce contrastive stress correctly. Only final syllable intensity differences were noted, but proved to be inadequate cues for contrastive stress. Vibrotactile stimulation resulted in changes, specifically significantly higher Fo for initial stressed vs unstressed syllables, significantly louder intensity for final stressed vs unstressed syllables, and significantly longer duration for final stressed vs unstressed syllables. Perceptually, listeners judged D's contrastive stress placement as always occurring on the final syllable previbrotactile stimulation and as 78% correct postvibrotactile stimulation. N's contrastive stress placement was always correct. It was concluded that use of vibrotactile stimulation enhanced D's production and resulted in listeners' perceptions of correct prosody.

Some acoustic evidence for vocal abuse in adult speakers with repaired cleft palate

Acoustic evidence for vocal abuse in adult speakers with cleft palate and hypernasality has not been reported. This study was undertaken to determine if there was acoustic evidence of inappropriate vocal fold adduction during stop consonant production in this population. The results indicated that spectrograms of speakers without cleft palate and severe hypernasality exhibited acoustic characteristics different from spectrograms of speakers without cleft palate and speakers with cleft palate and mild hypernasality. Specifically, voiceless stop productions of severe hypernasal speakers resembled voiced stop productions. Their vocal folds were inappropriately adducted to provide a constriction inferior to the inadequately functioning velopharyngeal port to minimize the nasal air leak. The acoustic evidence supports the hypothesis that a cause of vocal abuse in the cleft palate population is due to compensatory laryngeal valving activities secondary to severe hypernasality.

The pragmatic processing of intonation and word order in 2.0- to 4.0-yr.-old children

This study investigated the roles intonation and word order play in the development of strategies in pragmatic discourse by the young child learning language. Four groups of children ranging in age from 2.0 to 4.0 yr. of age were given a 44-item protocol. The children responded to the pragmatic intent of the stimulus sentences differently as a function of intonation contour, word order, and age. The significantly greater number of responses observed with interrogative intonation in the youngest age group (24 to 29 months) may serve a social-conversational function for the child of holding an end in the conversation during discourse when no other response is available. A linguistic competency level might be required before word order alone signals the pragmatic intent of an utterance. This level appeared to occur at 30 mo. of age since prior to this age the children did not respond to the pragmatic intent of the sentences based on word order alone. Lastly, it appeared that the children's responses to the pragmatic intent of the stimulus sentences was a developmental phenomenon dependent upon the variables of age, word order, and the presence or absence of interrogative intonation.

Response patterns of children to interrogatives with differing syntactical complexities

This study systematically varied the syntactical complexity of 15 interrogative types by using adult and telegraphic syntax patterns. Different surface structures were generated but the same deep structure was maintained. 25 male and 25 female children between the ages of 34 and 72 mo. served as subjects. The purposes of this study were (a) to determine the hierarchy of response rate by children with normal and delayed language development and (b) to determine whether adult or Telegraphic syntax was responded to with greater accuracy by children with normal and delayed language development. The language-delayed group appeared to follow the same developmental hierarchy of interrogative acquisition as the normally developing group for both adult and telegraphic speech syntax. The normal group performed significantly better than the delayed group regarding types and syntactical complexity of interrogates answered appropriately. In addition, evidence was obtained for the preference of using syntax of adult speech over telegraphic speech syntax when interrogating a child whose language is delayed or normally developing.

Influence of intonation on auditory sequential memory skills

This study was designed to investigate the effect of intonation on the auditory sequential memory spans of children normal in language development and those with delay. Analysis indicated that intonation as a cue did not facilitate recall of monosyllabic nouns presented in sequences of two, three, four, and five words. Children with a language delay of six months or longer had spans of one word less than children with no language delay. Neither recall nor the memory span was related to chronological age over the range of 42 and 72 mo. for either group of children.

Effects on superiority of ear of intonation of dichotically presented sentences

A dichotic listening paradigm utilizing sentences of three monosyllabic words examined the effects of intonation on superiority of ear. Five types of intoned contours, i.e., declarative, interrogative, imperative, conditional, and monotone, were employed. Subjects consisted of 20 adults who had normal hearing bilaterally, were native English speakers, and were righthanded in 100% of their daily activities. The results indicated that, when three monosyllabic work sentences with four different intoned contours were dichotically presented, superiority of neither left nor right ear was evidenced. However, the declarative intoned contours, being linguistically less marked, were perceived with significantly less accuracy than the relatively more marked interrogative, imperative, and conditional intoned contours.