1.

Definition: Vocal cord nodules, sometimes called singer’s nodules or nodes, result from
repetitive overuse or misuse of the voice. These callous-like growths develop in the
midpoint of the vocal folds. Vocal cord nodules look like calluses under the microscope and
are occasionally associated with abnormal blood vessels. When they are present, the vocal
cords cannot close completely when they vibrate to produce the voice. This causes the
voice to sound breathy and hoarse. Women between the ages of 20 and 50 years old are
more prone to vocal cord nodules, but both men and women can be affected
2. Causes of Vocal Cord Nodules: Vocal abuse and Misuse are the most common causes
a. Vocal abuse including excessive shouting, screaming, or crying,
b. Vocal Misuse including use of an incorrect pitch or volume especially while singing
C. Other factors including chronic upper respiratory infections or allergie and
Laryngo-pharyngeal reflux
· 3. Appearance of Vocal Cord Nodules from Vocal Misuse and Abuse: During an
important vocal end, the increase of intensity [vocal abuse/vocal misuse] causes vocal fatigue
which drives the adults to take a vocal rest. However, in some circumstances, the adult does not
take this vocal break. As a result, the vocal cord muscle tension will increase resulting in stiff and
thick vocal cords. This is responsible for the appearance of air leakage at the level of the larynx and
may affect the voice quality. Then, the individual will try to increase the pressure of the air passing
between the vocal cords in order to maintain the voice production. This will continuously increase
the friction when the vocal cords collide and will result in the appearance of vocal cord nodules.
When vocal cord nodules are present, the quality of the voice will be affected resulting in
dysphonia/voice disorder.
4. Definition of Voice Disorder/ Dysphonia: Dysphonia is the impairment of voice production.
Voice disorders are defined as a deviation in pitch, loudness, or vocal quality relative to a person’s
age and gender. While many patients experience dysphonia as a natural part of the aging process, it
can be a symptom of a serious underlying condition. Clinicians need to recognize that when
patients present with dysphonia for longer than four weeks and when it is associated with risk
factors or other concerning signs and symptoms, further evaluation is warranted.
5. Symptoms of dysphonia:
· Hoarseness: the normal pitch and intensity of the voice change, so that the voice appears
raspy and strained.
· Breathiness: the air escapes during vocal cord vibration due to abnormal closure of the
vocal cords.
Multiple tones: the voice pitch might suddenly change when the person is using his/her voice.
6. Role of SLP
a. Assessing the patient’s voice: Perceptual evaluation including anamnesis, auditory
perceptual evaluation [evaluating the patient’s voice based on 5 criteria: roughness,
breathiness, strain, pitch deviations and loudness deviations]/ instrumental evaluation: In
this type of assessment, the SLP uses some software to calculate some acoustic
measurements and compare them to the standardized measurements. These acoustic
measurements include the voice fundamental frequency and intensity, vocal range
[maximum and minimum intensity and frequency], maximum phonation time, voice breaks
b. Putting a diagnosis of voice disorder
c. Treatment plan: voice exercises [production of voiced consonants, combination of a voiced
and unvoiced consonants, voiced consonants with a long vowel, production of plosives with
 a vowel, replacing a specific consonant in a text by another consonant, production of nasal
consonants]/ behavioral changes [vocal hygiene] and breathing and relaxation techniques

2) Acquired Dysarthria:
- Definition: Dysarthria is a group of neurogenic speech sound disorders that affect
the strength, speed, range, steadiness, tone, or accuracy of the movements needed for
breathing and speech production in adults. It involves an impaired ability to perform
the motor movements that are important for producing speech. Muscles can be
impaired with respect to range, direction, strength endurance, speed or timing.
- Signs and symptoms may include: (according to ASHA web)

· Short phrases — Reduced loudness — Pitch changes– Change in voice

quality– Imprecise articulation of consonants — Vowel distortions —
Hypernasality/ audible nasal emission — Changes in prosody of speech/ abnormal
rate — Involuntary movements of the head, jaw, face and tongue — Abnormal
reflexes

- Role of SLP: Speech therapists play a major role in screening, assessing, diagnosing
and treating individuals with Dysarthria. The following roles are:
- Screening individuals who are suspected to have dysarthria and determining whether
they need a further assessment ( language/ feeding and swallowing) or other therapies
( psychomotor/ occupational/ physical).
- Administering a comprehensive assessment of speech, language and communication
that is culturally and linguistically relevant to the individual’s unique needs and
complaints.
- Diagnosing whether the individual has dysarthria or not, and determining its severity
and functional impact.
- Establishing the prognoses and progression of dysarthria for the individual.
- Collaborating with other professionals and families to help manage the patient’s
symptoms and achieve functional communication.
- Provide the appropriate treatment services for the individual with dysarthria using the
right approaches and techniques.
- Determining the appropriate service dismissal criteria ( when to stop the therapy ).
- Counseling the clients and their families concerning communication-related concerns
and provide them with education on preventing any further complications related to
dysarthria.

- Assessment areas: A typical dysarthria assessment is as follows:

- Case history ( Medical history/ auditory, visual, motor, cognitive, language
and emotional status/ Educational and cultural backgrounds)
- Non-speech examination ( assessing the speed, strength, range, accuracy,
coordination, and steadiness of the speech subsystem using objective
measures. This includes: cranial nerve exam, observing the face and neck
tonicity, assessing the pulmonary support through sustained vowel production)
- Speech production ( assessing the vocal quality, pitch and loudness/
assessing the motor speech planning ad articulation processes/ assessing
 speech intelligibility by collecting a speech sample/ assessing the
comprehensibility of the individual’s speech/ assessing the receptive and
expressive language skills in both oral and written modalities)
- Cognitive-communication ( assessing the nonverbal skills that may be
affected by cognitive deficits such as the attention, memory and executive
functions)
- Swallowing ( assessing the swallowing function to determine if the dysarthria
is associated with a feeding and swallowing disorder such as dysphagia)

3) Dementia Disesae:

- Definition: Dementia is defined as a syndrome, or a group of related

symptoms, that result from acquired brain damage or disease. It mainly affects
men and women over the age of 65, however occasionally younger people can
have dementia.
- Characteristics and symptoms: It is characterized by progressive decline in
memory, impaired problem solving skills, problems in attention and listening,
impaired cognitive skills and executive functioning, psychosocial and mood
changes, behavioral symptoms, swallowing difficulties, and voice problems.
Moreover, symptoms include problems in communication and language such
as less concise discourse with fewer ideas, word-finding difficulties,
grammatical errors, loss of meaningful speech, impaired ability to compose
meaningful written language, difficulty following and maintaining
conversation, language comprehension deficits, and difficulty following
multistep commands.

To be noted, the severity and rate of deterioration depends on the stage of a

person’s dementia, cause, lifestyle, and other medical conditions. There are
many different types of dementia; the most common forms include alzheimer's
disease, vascular dementia, lewy bodies dementia, and fronto-temporal
dementia. Most dementias result from degeneration in cortical and/or
subcortical structures and neural pathways, and/or chemical changes that
affect neural functioning. Moving to the main three stages of dementia: in the
early stage, it is common for patients to have gradual confusion and mood
changes, and routine tasks take longer time to be completed and with less
focus. In the middle stage, the patient presents progression of the early
symptoms.. In the final stage, most patients lose the ability to recognize their
beloved ones and even themselves in the mirror; as well, they will lose the
ability to communicate and use meaningful language.

- Role of SLP: A speech and language pathologist plays a fundamental role in

prevention, screening, assessment, diagnosis, and treatment of dementia
patients. An SLP provides prevention information to individuals and groups
known to be at risk for dementia, and he/she educates other professionals
regarding the role of SLP with dementia patients. Additionally, the SLP
conducts screening and assessment in areas of communication, receptive and
 expressive language, cognitive skills, eating, drinking, and swallowing to
detect any difficulties/disorders associated with dementia, and thus provide an
appropriate therapy plan. Furthermore, the SLP collaborates with and refers to
other professionals in the multidisciplinary team (neurologists, geriatricians,
neuropsychologists, nurse practitioners, physical/occupational therapists,
nutritionists, and social workers) based on the specific needs of every patient.
As well, the SLP collaborates with the patient’s family and offers help and
advice for dementia patients and improve the coping strategies to support
independence and confidence of the patient.
- Assessment areas:
1. Receptive and expressive language: all the components of oral
language
2. swallowing abilities if concerned: through an observation of mealtime
and when having different swallowing trials
3. hearing and visual skills: for being commonly impaired among the
aging population
4. cognitive-communication domains related to dementia (memory;
attention; disorientation to time, place, and person; problem solving)

- Treatment: Overall, the primary goal is to maximize the individual's quality of life
and communication skills, by working on lost functions and teaching coping skills in
order for patients to manage their disease as effectively as possible, also slows down
the progression of the disease. One effective and interesting method of therapy is the
creation of a memory book, which can provide visual cues for dementia patients. A
memory book contains photos and brief descriptions to refer back to when a senior
has questions relating to his or her identity, members of the family, etc.

4)Wericke’s Aphasia:

Aphasia is an acquired neurogenic disorder that involves varying degrees of impairment in

four primary areas: • Spoken language expression • Spoken language comprehension •
Written expression • Reading comprehension However, it can be caused by strokes or head
injuries most typically, in the left hemisphere, or by other factors such as head trauma, brain
tumors, multiple sclerosis, or a degenerative impairment. Aphasia is an umbrella term for
eight types of Aphasia broadly classified as either fluent or non-fluent. In Fluent Aphasias, a
patient is able to produce connected speech, with a relatively intact but meaningless sentence
structure. Wernicke's Aphasia is 1 type of fluent Aphasia (aka. Fluent, receptive, or sensory
aphasia)

· Clinical Symptoms of Wernicke's Aphasia:

o Lesion Site: Posterior third of superior temporal gyrus

o Spontaneous Speech Level: Fluent, excessive, semantic, and phonemic

substitutions

o Production Level: Poor word production, and good sentences with empty
content
 o Comprehension Level: Poor sentence comprehension

o Repetition Level: poor repetition of words/phrases.

o Literacy Level: Poor reading comprehension and Writing deficits

· Signs of Wernicke's Aphasia: Anosognosia: lack of awareness of difficulties

o Logorrhea: pathological excessive and often incoherent talkativeness

o Jargon and neologisms: nonsense words based on language sound patterns.

o Frequent paraphasia: words that sound like (phonemic paraphasia) or mean

something similar to (semantic paraphasia) the intended word.

o Massive impairment of auditory-verbal understanding

o Disruption of reading comprehension + Elements of verbal deafness

o Press of speech: talking over others or taking turns in communication

· Therapy Criteria: Fluent aphasia is a result of a broken phonological system. This

means the person cannot tell that the sounds they are using are incorrect. Therefore,
treatment will focus less on physical speech exercises and more on learning to process
words again. For example, some treatments for Wernicke’s aphasia focus on improving
the person’s attention skills, which may help the patient recognize and correct their
speech errors.

· Treatment Plan:
O Auditory Comprehension focus: SLP works on Attention and retention: by tasks
about phone number, recipe steps / comprehension of single words - spoken
sentences - discourse / Auditory Compactum: understanding single words -treatment
of perseveration - sentence verification - yes/no questions - pre-stimulation
oImproving comprehension of words / conversation

o Enhancing naming: SLP must select words that are client-specific and functional
nouns and some easy, common, picturable verbs; move into verbs, adjectives, and
adverbs later (moving from known to unknown)

o Expand meaningful utterances: Start with shorter sentences with one subject and
one verb; syntactically simpler sentences; active over passive

o Improving reading: sequenced as survival reading - newspapers, books and letters

- phrases and sentences - reading of paragraphs

o Improving writing: functional words - lists - short notes - filling out forms –
letters

o The setting of PACE: to improve conversational skills.

o Improving self-monitoring: self-monitor and realize what they're saying

 o Family inclusion

ALS:

Overview: Amyotrophic lateral sclerosis (ALS) or Lou Gehrig's is a degenerative nervous

system disease that destroys nerve cells in the brain and spinal cord, resulting in muscular
weakness, it is named after the baseball player who was diagnosed with it. The cause of ALS
is largely unknown to doctors, some speculate that the disease is hereditary. Muscle twitching
and weakening in a limb, as well as slurred speech, are common symptoms of ALS. ALS
eventually affects the muscles that allow the person to move, speak, eat, and breathe. No
known treatment has been discovered to date. The core symptoms that are mainly affected in
speech and require Speech Therapy intervention are Slurred speech and/or trouble
swallowing.

Dysphagia:
Dysphagia is a swallowing disorder that involves the oral cavity, pharynx, larynx, and
esophagus. There are two types of dysphagia, oropharyngeal dysphagia and esophageal
dysphagia. Oropharyngeal dysphagia occurs when there is difficulty moving the food bolus
from the oral cavity to the esophagus. However, esophageal dysphagia occurs when there is
difficulty passing the solid/liquid material through the esophagus. In fact, the etiologies of
dysphagia differ from patient to another, and may include, congenital malformations, stroke,
degenerative diseases, tumors, traumatic brain injury, muscles dystrophy, gastro-esophageal
reflux, surgery involving the head and neck, chemo-radiation for head and neck cancer
treatment, tracheostomy or oral intubation, and aging.
In addition, a wide range of signs and symptoms could reveal dysphagia such as, poor oral
management, malnutrition, dehydration, chocking, recurring aspiration pneumonia, and
pulmonary infections. These symptoms may lead to social and psychological consequences
resulting in limitations in the patient’s physical or social activities.
Speech-language pathologists (SLPs) play a vital role in providing dysphagia services, and
are considered integral members of a multidisciplinary team that assess, diagnose, and
manage oral and pharyngeal dysphagia. SLPs also recognize signs of esophageal dysphagia
to make referrals for its diagnosis and management.
GLOBAL APHASIA
1. Introduction:
Aphasia is an impairment of language function which is localized to the dominant cerebral
hemisphere. Global Aphasia is the most severe form of aphasia and is applied to patients who
can produce few recognizable words and understand little or no spoken language. Patients
with Global Aphasia can neither read nor write.
2. Etiology:
Global Aphasia is caused by injuries to multiple language-processing areas of the brain,
including those known as Wernicke’s and Broca’s areas. These brain areas are particularly
important for understanding spoken language, accessing vocabulary, using grammar, and
producing words and sentences. Causes can vary from a stroke, tumor, infection or trauma.
3. Characteristics of global aphasia:
Global aphasia is the most severe form of aphasia. It can cause symptoms affecting all
aspects of language. These are some of the ways a person with global aphasia may have
trouble communicating. Regarding speaking and production, people with Global aphasia have
troubles in speaking and repeating speech. Their utterances are limited and aren’t
understandable, and they tend to make a lot of grammatical mistakes. If words are spoken, it
is likely to be a single word and might contain errors, such as paraphasias. Semantic
paraphasia is when an entire word is substituted for the intended word (such as saying “son”
instead of “daughter” or “orange” instead of “apple’). Phonemic paraphasia is when a sound
substitution or rearrangement is made, but the stated word still resembles the intended word
(examples include saying “dat” instead of “hat”). Furthermore, they have difficulty finding
words (anomia). Moving to language comprehension, such patients have problems in
understanding others and comprehending fast speech. They answer simple yes or no
questions incorrectly and they take more time to understand spoken language. When it comes
to writing difficulties “agraphia”, the difficulties show through misspelling words, misusing
grammatical rules, substituting incorrect letters or words and using incorrect words. Finally,
on the level of reading, global aphasia patients suffer from difficulties in understanding texts
and figurative language, they are unable to sound out words, they struggle to recognize sight
words, and they have difficulty comprehending written material. Moreover, people with
global aphasia may have problems with their relationships, jobs, and social life because they
have trouble understanding other people. They may develop depression or feel isolated if they
don’t have support and regular social interaction. Thus, not being able to speak, read or write
also limits the career choices of people with global aphasia.

Broca’s Aphasia:
Definition: Damage to the Broca's region of the brain, which is located in the frontal lobe,
usually on the left side, causes Broca's aphasia. This part of the brain is responsible for
speech and motor movement. Broca's aphasia patients have difficulty speaking effectively,
but their comprehension can be preserved. Non-fluent or expressive aphasia is another name
for this type of aphasia.
Signs and Symptoms of Broca’s Aphasia:
· Poor or nonexistent grammar makes it difficult to compose entire sentences
· Delete words from the sentences, in which for example, individual with aphasia might
say “apple me” instead of “I want an apple”
· Verbs are more difficult to use correctly than nouns

· Sound and word articulation problems

· Difficulties repeating what others have stated

· Reading difficulties

· Frustration

Role of SLP with patients having Broca’s Aphasia:

Number of specialists work with people having broca’s aphasia in order to ensure the
restoration of their acquired skills that have been affected due to the stroke, injury, trauma…
which they had. Speech and language pathologists are one of the specialists who work with
this type of patients to rehabilitate their skills at the level of speech, language and
communication. In the case of broca’s aphasia the speech therapists assess the patient’s ability
to express more than to receive since broca’s aphasia affects the individual’s ability to express
while his/her receptive skills are preserved. Speech therapists assess the following key
language areas:

· Spontaneous speech (often including picture description and conversational

interaction)

· Repetition (words and sentences)

· Comprehension of spoken language (for example, following commands, answering

‘yes’ ‘no’ questions)

· Word finding (e.g. naming body parts, objects and picture stimuli)

· Reading and writing

Based on the performance of the individual and the results of the assessment the speech and
language pathologist will set a treatment plan including the goals that he/she will target
throughout the therapy journey. Mainly, when dealing with patients having broca’s aphasia
the aim of the therapy plan and the most basic goals are rehabilitating the lost language
abilities and enhancing the communication skills in order to enable the patient to re-express
in a smooth manner. For achieving these goals, the speech therapist use variety of techniques
and approaches that varies in their complexity.

Some Examples of the techniques used:

ü Automatic Phrases

ü Object Naming

ü Sentence completion

ü Naming from description

ü Definitions

ü Category Naming

ü Rhyming words

ü Picture Description

Automatic Phrases: Series of numbers or words will be used and the speech therapist has to
say each series aloud with pointing to each number or words said (Example: 1 2 3 4 5 6 7 8 9
10/ 10 20 30 40 50 60 70 80 90 100/ Monday, Tuesday, Wednesday, Thursday, Friday,
Saturday, Sunday).

Sentence Completion: The patient is asked to complete a sentence. The sentence is either
read by the patient or the Speech therapist and the response can be written or said orally
depending on the objectives targeted. (Example: This room is either too hot or too …/ you are
either wrong or … / the answer can be true or …/ Do you have any brothers or …)

Naming from Description: The patient is asked to name what is described. The description
is either said by the therapist or have the patient read it. (Example: This animal is black and
white, is from Africa, and looks like a horse. / This vehicle has many seats, wings, and can
fly./ These are worn on your feet and are usually worn with shoes.)

Ø In addition to the techniques, there are other approaches used by speech therapists to
improve expressive language such as, VNeST (Verb Network Strengthening Treatment) and
intention manipulation.

Ø When dealing with patients having broca’s aphasia, the role of speech and language
pathologist is not limited to working with the patient himself only, but rather his/her role
involves other parties including the family member of the patient and specialists who might
the SLP refer to (example: psychomotor, occupational, or psychologists). The SLP has a
significant role in dealing with the family member and the care giver of the patient in which
he/she will provide guidelines, recommendations (example: Keeping your language clear and
simple and speak slowly/Reduce background noises and distractions/Asking careful questions
that only require a ‘Yes’ or ‘No’ answer instead of open ended questions/ Give them plenty of
time to respond./Don’t ask too many questions too quickly since they may feel overwhelmed
and become frustrated), and techniques to be used with the patient at home. The purpose of
this collaboration is to reach the best that can be reached in the therapy journey.

Ø When working patients having broca’s aphasia the SLP should focus on working on the
areas and skills that are important and necessary for the patient’s functionality in his everyday
life. For example if the patient was a carpenter the SLP should work on restoring the
categories that involve this area. So the SLP will always work depending on the patient’s
needs and necessities.

The SLP will know how to deal with a patient with broca’s aphasia, in which he/she know
that this patient had lost what he has acquired suddenly so accordingly what is he/she going
through will not be easy for that the SLP needs to take the patient’s mental state into
consideration
Right Hemisphere Damage:

The right hemisphere is engaged primarily in complex linguistic processing and the
emotional, nonverbal aspects of communication. It has responsibilities at the level of
pragmatics and semantics (word and discourse). The right hemisphere damage (RHD) is an
acquired brain injury. It results from a variety of causes, such as: traumatic brain injury,
stroke, etc.… In the case of right hemisphere damage, the semantic processing of words
(understanding jokes and emotions), discourse processing including discourse, prosody, and
pragmatics can be affected. As for the expressive abilities, the discourse deficits are marked
by verbosity, digressions from topic, and disorganized thoughts. On the other hand, syntax,
grammar, phonological processing, repetition, and word retrieval typically are not affected. In
addition, the eye contact will be reduced with poor turn taking and decreased conversation
initiation. This damage can also cause impairments in many cognitive domains that interfere
with the communication abilities. Some of these impairments, that greatly affect both spoken
and written language, can be: Anosognosia (reduced awareness of deficits) and visual neglect
(aspects of visual stimulus are ignored). It may be associated with dysarthria, emotional
disorders, dysphagia, and hemiparesis/hemiplegia. But it is important to note that the
outcomes of RHD significantly vary from patient to another.

The SLP roles start by screening individuals who show the communication and cognitive
deficits that suggest the presence of RHD to determine the need for further assessment and
referral to other services. Then, conduct a well-designed culturally and linguistically
appropriate assessment for communication, language, and cognition. After that, diagnose the
communication disorders that resulted from RHD by mentioning their characteristics and
functional impact (severity and prognosis). Moreover, develop an individualized treatment
plan in collaboration with the patient, family, and multi-disciplinary team. The SLP provides
intervention, support services, and progress documentation. Also, the SLP educates and
counsels the professional, patients and their families with relevant recommendations about
communication for the sake of facilitating participation with family and community contexts.

Several factors may affect the screening and comprehensive assessment such as: spoken
language(s), post-stroke depression, fatigue (break testing in to shorter sessions), upper
extremity hemiparesis (may affect writing abilities), medical status (chronic pain, new
conditions, or potential impact of prescribed drugs), etc. Thus, questionnaires to patient and
his/her family in addition to standardized and non-standardized methods are used to screen
oral motor functions, speech production skills, receptive and expressive skills of spoken and
written language, pragmatics, and other cognitive skills (attention, memory, and executive
function) as they relate to communication, swallowing, unilateral visual neglect, and hearing.

The assessment process includes case history for the patient, self-report to know the
functional communication struggles and success the patient is facing and his/her goals and
preferences, oral mechanism evaluation (muscles ability, tone, phonation, and steadiness),
language assessment (expressive and receptive skills at the level of discourse, use of prosody
to express emotions, interpretation of abstract language, and pragmatics), cognitive skills (all
types of attention and memory, problem solving and reasoning, judgment, executive
functioning, impulsivity, facial recognition, awareness of deficits, and visuospatial awareness
in one's environment), and feeding and swallowing assessment (in the different phases of
swallowing: preparatory, oral, pharyngeal, and esophageal). Some of the assessment batteries
are the following where they can administered in their entirety or in selected subsections after
adapting them to culture, such as Right Hemisphere Language Battery, 2ndEdn (Bryan, 1994)
that covers the Lexical semantics, non-literal language, humor, inferences, prosody areas.

The therapy targets the difficulties caused by RHD including attention and listening
problems, communication deficits, swallowing difficulties, voice and speech problems. The
therapy should focus on social communication to be able to have effective communication,
attention, listening, and other impaired cognitive abilities.

Vocal Cord Paralysis/ Paresis

Definitions:

The immobility of the vocal cords due to a neurologic injury, is the case of vocal cord
paralysis. Whereas, vocal fold paresis indicates hypomobility of the vocal fold (s) due to
neurologic injury. It may result from weakness of the recurrent laryngeal nerve (RLN),
superior laryngeal nerve (SLN), or both. Nerve injury can be bilateral or unilateral. Vocal
paresis may present as dysphonia, hoarseness, chocking episodes, throat pain and breathy
vocal quality (Rubin et al., 2007).

Causes of Vocal cord paresis and paralysis can be iatrogenic (caused by a medical treatment
or examination) such as thyroid surgery, anterior cervical spine surgery, and thoracic surgery.
Causes cam be non-iatrogenic such as viral infections and other neurologic diseases such as
Multiple sclerosis, Parkinson, Huntington, myasthenia gravis (Rubin et al, 2007).

Evaluation

The assessment of vocal cord paresis/paralysis starts with the patient’s history and
examination.

Gathering information from the patients inquires to known about his complaint and the
symptoms: is he feeling fatigue while talking, suffering from hoarse voice? Etc.

Ask about the medical history of surgeries, medication, intubations, traumas and hormonal
intake or if he/she suffers from any disease or neurological condition. Moreover, take
background information of the patient: his/her profession (to know if the patient’s work
requires him to use his voice a lot, in the case of a teacher, a singer, a lawyer, etc.), smoking
and alcohol habits, if he/she exercises a lot (excessive and improper way of weight lifting
would cause vocal trauma)

A physical examination includes: head and neck palpation. This helps check the presence of
inflammation or irritation. Close attention should be taken in regards of examining cranial
nerves, particularly the Vagus Nerve (the nerve which provides motor supply to the larynx.
Assess the cranial nerve by causing pressure to the back of the tongue- for right and left sides
and see if this action evokes a gag reflex or not. Secondly ask the patient to produce /Ah/
sound. Normally the soft palate elevates upward while the uvula elevates in symmetry. In
case of lesion of the Vagus nerve, the uvula will elevate in the opposite way of the lesion).
Also, observe the posture of the patient while breathing and talking: posture during standing
and sitting, the shoulder’s position, pelvis, knees, head and neck.

The Slp should check for the breathing patterns: abdominal, thoracic, clavicular. In addition
to the coordination of respiration and phonation (breath-holding patterns, habitual use of
residual air, etc.)

Proceeding, the therapist should pass a perceptual assessment for the patient to assess his
voice quality by taking speech sample. Does the patient have a breathy, hoarse, rough, strain
and etc.? phonatory test to assess the Maximum phonation time (MPT), pitch/fundamental
frequency, rate of speech and resonance. Tests such as repetitive phonatory tasks are great
indicator for vocal cord paresis (Rubin et al, 2005)

It is crucial to mention that in addition to all of the above, an instrumental assessment should
be done, by referring the patient to an otolaryngologist. The latter uses laryngoscopy with
either a rigid or flexible endoscope, or both to accurately visualize the voice box for proper
diagnosis.

Most importantly, the initial assessment is very important to document, as it estimates to what
extent will voice therapy improve the condition without subjecting the patient for surgery.

Treatments

Treatment of Unilateral Vocal cord paralysis/paresis focuses on eliminating aspiration as well

as enhancing breathing and voice quality. If there is no aspiration, treatment focuses on the
desires of the patient to improve his/her voice. In most of the cases, the laryngeal nerve
recovers with therapy especially if the injury is not caused by transection of the nerve. In this
case, it is the best to delay surgical intervention for approximately 1 year and apply voice
therapy unless the cranial nerve is confirmed to be resected or divided (Rubin et al, 2005).
ASSESSMENT TESTS:

Test Name Populatio Age Skills assessed and how/ Notes to consider
n/ characteristics of test
standardi
zed on..

CELF ( Clinical American 5-21 - Language content, use - Performance is

evaluation of and structure. highly influenced
language - Made up of 18 subtests by cognitive
fundamentals) - Verbal administration to abilities/impairme
picture stimuli or nt
checklists - Cannot be
- Completion time is 30-45 re-administered
minutes based on subtest frequently
- The 18 subtests tap into
the cognitive, oral and
written language skills of
the individuals tested.
Assessed skills include:
- Overall listening,
speaking, reading
and writing skills
(based on age)
- Following directions
- Syntax and
morphology(product
ion and
comprehension)
- Linguistic concepts:
lexicon and
semantics(productio
 n and comprehen.)
- Memory/ sentence
recalling skills
- Vocabulary
- Reading
comprehension
- Structured writing/
spelling
- Pragmatics (verbal
and nonverbal social
skills)

Phonological US 5-10 years *awareness of the oral *performances on

Awareness population language segments each of the tasks has
Test-2 been correlated with
*3 sections: phonological success in early
awareness section (6 reading and spelling.
subtests: Rhyming,
segmentation, isolation, *important to be
deletion, substitution, and used, in the second
blending); place, for children
Phoneme-Grapheme section with written
(2 subtests: graphemes and language difficulties,
decoding subtests); spelling especially the ones
section (optional) who previously had
oral language
* Each response receives a 1 difficulties.
for a correct response or a 0
for an incorrect response.

*There is a Discussion of
Performance section in the
Examiner's Manual that
helps the examiner move
from assessment to
treatment.

Abecedarian US Grades Letter knowledge

Reading population Kindergarten Comprehensive test for significantly
Assessment -Grade 1 reading's essential domains,
influences the
where six reading skills are
acquisition of
mentioned.Early Reading phonological
Skills awareness and
phonological
A) Letter Knowledge:
processing skills.
identity the names of the
letters And We can only
access meanings of
B) Phonological words we already
Awareness know.
1. Rhyming Perception:
identify if the pair of words Using the flowchart,
rhyme SLPs should be
strategic about
2. Phoneme Identity -
giving assessments.
Perception: listen for the
To a certain extent, it
sounds told
is necessary to use
3. Rhyming Production: discretion when
come up with 2 words that determining where to
rhyme with given words begin testing
different children.
4. Phoneme Identity - But All children
Production: listen to two should get the
different words that share a vocabulary
sound. The child must list assessment
three words that have the
sound. Administrators
should be strategic:
C) Phoneme Awareness: it is not necessary to
Subtests: a pre-test and three give every part of the
tasks. Pre-test: Checks Abecedarian to every
concepts of first & last. student

- Assessments
increase in difficulty:
1. First Sounds 2. Last if a student is
Sounds 3. Segmentation struggling with the
Letter Knowledge
D) Alphabetic Principle:
Aim: learn how to break assessment, then it is
words apart and sound them unlikely he will
out. perform well on the
Decoding section.
o Instruction: look at two
words; a long and a short
one, where the child needs
to point to a heard word.

E) Vocabulary (passed to
all kids) (to test oral
language aspect)
 1. Production: what the
word ALONE means, Ask
the child to use the word in
a sentence.

2. Antonyms:Child is
asked to choose the
antonym of the given word
out of 3 choices.

3. Synonyms:Child is
asked to listen to these
words and tell which word
means the same thing as a
given word

F) Decoding

1. Fluency: o read all

twenty words out loud
during one minute.

2. Irregular Words: read

all ten words out loud.

3. Regular Words: read all

ten words out loud.

GFTA-2 US 2-21 GFTA-2 Test Sections This is an

English • Measurement of articulation test and
speaking spontaneous production of does not give score
population sounds in words to determine whether
(Sounds-in-Words) its a phonological or
• Measurement of articulation disorder
articulation skills in a task
closer to authentic speech
(Sounds-in-Sentences)
retelling a story
• Measurement of
stimulability (Stimulability)
The stimulability is used to
determine the relative ease
and which the examinee can
be produced previously
misarticulated sounds in a
 situation that gives them
every advantage of Visual
and auditory modelling

Evalo BeBe French 0-20 months • Anamnesis:. It aims to All the materials
population protocol define a development during the
20-27 profile in the dimensions parent-child
months studied and to identify any interaction/ SLP
protocol warning signs or anomalies child interaction are
[developmental milestones, provided by the test.
medical history…]
• Observing SLP-Child
Interaction: A natural
situation must be proposed
and filmed by the speech
therapist: general
appearance, audibility, oral
motor skils, relation to
others [exchange, request,
joint attention], relation to
objects [object
permanence], expressive
skills [naming
objects/pictures] and
comprehension [body parts
and simple instructions].
•Observing Parent-Child
Interaction: focus on
pragmatic skills
[reciprocity, feedback, use
of prosody, ]/
• parental report: This is a
standardized questionnaire
intended for parents, it
proposes questions that
contextualize the child’s
behavior in daily life
situations.

TOCS ENGLISH 4-12 years Rapid naming test

SPEAKIN old It helps in:
G -Determining how fluently
POPULAT children produce single
 ION words in a time-stressed
context.
-Allowing the examiner to
analyze the child's responses
Modeled sentences
This evaluates children’s
ability to speak fluently in a
context in which sentences
that vary in syntactic
complexity.
Structured Conversation
This evaluates children’s
ability to speak fluently in a
dialogue context.
Narration
This assesses children’s
ability to speak fluently in a
monologue context.

Boston Adults It assesses:

Diagnostic Perceptual modalities :
Aphasia - Auditory
Examination - Visual
(BDAE) - Gestural
Processing functions:
- Comprehension
- Analysis
- problem-solving
Response modalities:
- Writing
- Articulation
- manipulation
Subclasses:
- Conversational and
expository speech
(simple social
responses/ free
speech/ picture
discription)
- Auditory
comprehension (
word
comprehension/
commands/ complex
 ideation/ syntactic
processing)
- Oral expression
- Reading and writing
- Apraxia Assessment

O52 Not 4 and above Evaluate strategies that go https://www.faceboo

standardiz beyond rc: lexical domain, k.com/10691425631
ed morphological domain, and 63136/posts/168250
narrative (syntax) domain 5878493465/

EDA standardiz 4 to 11 years Evaluate oral lanuage :

ed lexicon expression,
compprehension,
syntax-morphosyntax
expression and
comprehension, phonology
and fluency.
Nonverbal functions:
graphics, visual attention,
planning, visuo-spatial
reasoning, visual
discrimination, praxis
Learning: reading,
transcription and
mathematics.

The Illinois Test Arabs 4-12 years ITPA consists of 12 subtests

of Population the subtests are divided into
Psycholinguistic (Egyptians two parts:
Abilities specificall ● children aged 6 years or
(ITPA)-Arabic y) less.
version ● children aged more than 6
years

The test covers 12 areas of

functioning (cognitive
processes):
1. Auditory
reception:
‫االستقبال السمعي‬
• measures the
comprehension of the
spoken words by asking
yes/no questions.
‫بياكل؟) السيارةبتطير؟‬,‫)الكلب‬
2. Visual reception
‫االستقبال‬
‫البصري‬
• measures the
comprehension of pictures,
by associating the presented
picture to the one related to
it. This is done by
presenting a picture for 3
seconds, and then presenting
4 ones, and asking the child
to point to the one that is
related to it.
3. Auditory Association
((‫التداعي السمعي‬: It measures
the knowledge of
meaningful relationships
between spoken words, by
testing the child's ability to
complete sentences that are
homogeneous in their
linguistic context.
‎
‫والسكر‬ ‫…الحشيش أخضر‬
‎
‫والريشة‬ ‫…الحديد ثقيل‬
4. Visual Association
((‫التداعي البصري‬: it measures
the knowledge of
meaningful relationships
between visual symbols, by
testing the child's ability to
relate homogeneous or
related visual stimuli.
(If this picture is related to
this, then this is related to
which one)
5. Verbal Expression
‫التعبير‬
‫اللفظي‬
• measures the child's ability
to verbally express the
things he is asked to
explain. This is done by
showing the child familiar
objects (ball, cube,
envelope, button) and
asking him/her to give a
detailed description on it.
6. MANUAL
EXPRESSION
‫التعبير اليدوي‬
• measures the child's ability
to manually express ideas he
is asked to explain.
7. Auditory sequential
memory
• measures the auditory
short term memory, by
repetition of a serial of
numbers that are
represented auditory.
8. Visual sequential memory
• measures the visual short
term memory by the
reproduction of sequence of
symbols presented visually.
9. Grammatical Closure
(‫)االغالق اللفظي‬: It measures
the prediction of future
linguistic events based on
grammatical rules, by
testing the child's ability to
complete sentences with
related grammar.
‎
‫وهول‬ ‫… هيدا تخت‬
10. Visual Closure (‫االغالق‬
‫)البصري‬: it measures the
visual attention of the child.
11. Auditory
Closure:(‫ )االغالق السمعي‬it
measures the child’s ability
to recognize incomplete
forms, by asking the child to
complete a list of
incomplete words that vary
in their complexity. (Closes
what s/he hears) ‫ طيا‬for ‫طيارة‬
12. Sound Blending: it
measures the child’s ability
to combine parts of an
audible word to reach the
whole word.