10/30/2017

ORGANIC SPEECH DISORDERS

(DYSGLOSSIAS)
Mehmet Akif KILI, MD
Turkey

Organic Speech Disorder or

Dysglossia
It is an articulation disorder which arise as a result
of organic changes in peripheral speech organs or
in peripheral nerves that supply them.

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Aim
This presentation aims to classify dysglossias and
provide information on how to document speech
function but does not discuss detailed phonetic
information and speech therapy techniques.
If we can document speech function, then we will
be able to compare treatment modalities in terms
of speech function.

Background Information
Speech sounds are mainly divided into two groups,
namely, vowels and consonants.
Vowels: Classified according to different aspects:
Rounded or unrounded
Front or back
Open or closed
Monophthong or diphthong
Duration
Consonants: Classified according to three aspects:
Manner of articulation
Place of articulation
Voicing

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Articulatory Zones (AZ)

In clinical phonetics, consonants are classified according to their AZ:
First AZ (labial): Articulated between the lower lip and upper front teeth.
Second AZ (linguodental): Articulated between upper incisives, the upper
alveolar process, and tip of the tongue.
Third AZ (palatovelar): Articulated by the dorsum of the tongue and hard or
soft palate.
Fourth AZ (pharyngolaryngeal): Articulated in the pharynx and larynx.

I. AZ II. AZ III. AZ IV. AZ

Classification of Dysglossias
Dysglossias are generally classified according
to two aspects: (1) affected organs and (2)
etiology.
The lips, teeth, tongue, mandible, maxilla,
palate, velum, nasal cavity, and pharynx may be
affected.
Dysglossias may be organogenic, neurogenic,
and myogenic according to their etiological
factor.

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Etiology
Organogenic dysglossia: May be due to various causes:
Congenital malformations: Cleft lip and palate
Growth disturbances: Acquired dental problems
Benign lesions: Neoplastic or non-neoplastic
Malignant neoplasms:
Mass effect
Surgical excision
Radiotherapy
Injuries
Scars due to inflammatory diseases
Neurogenic dysglossia: results from peripheral nerve
paralysis.
In phoniatric practice, a nerve is considered peripheral after it has
left the brain stem.
Myogenic dysglossia: caused by muscular diseases such as
myasthenia gravis.

General Symptomatology
Symptomatology differs according to both affected
organs and etiology.
Labial dysglossias affect the I. AZ
Dental dysglossias affect the II. AZ
Lingual dysglossias affect the II. and III. AZ
Depending on damage, results can range from
minor distortions of a few consonants to total
failure of speech.
Congenital or prelingual problems are usually
compensated. Thus, speech problem may not be
readily observed.

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Labial Dysglossia
Articulation disorders resulting from labial
problems
Etiology:
Facial paralysis, lip injuries, surgical resection of
malignant lesions, and congenital malformations, such
as cleft lip can cause labial dysglossia.
Symptomatology:
Consonants which are articulated in the I. AZ ([p], [b],
[m], [f], and [v]), and rounded and front unrounded
vowels ([o], [u], [e], and [i]) are affected.

Case 1: Wedge Excision for the Lower

Lip (Squamous Cell Carcinoma)

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Dental Dysglossia
Articulation disorders resulting from malocclusion or other dental
problems;
Etiology: Several problems related to teeth can affect speech
mechanism:
Malocclusions and other dental problems
Tooth loss:
Physiological tooth loss in children
Total or partial tooth loss in adults
Dental prostheses and orthodontic appliances
Injuries (or surgeries) of the jaw and teeth
Symptomatology:
Particularly articulation of sibilants (s, z, sh, zh, ch, and j) are affected.
Other consonants which are articulated in the 2. AZ ([t], [d], [l], [n], and
[r]) and labiodental consonants ([f] and [v]) may also be affected.

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Case 2: Open-bite Deformity

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Mandibulary and Maxillary

Dysglossia
Minor problems will cause maloclussion and dental
dysglossia.
Large resections of the maxilla often create
connections between nasal cavities, paranasal
sinuses, and oral cavity, causing a strong
hypernasality.
In these patients, obturator prostheses are generally
used to close the openings between oral and nasal
cavity.
Resections of the mandible due to malignancies will
affect tongue function and cause lingual dysglossia.

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Lingual Dysglossia
Articulation disorders resulting from problems related to the tongue.
The tongue plays a major role in determining the shape of the mouth
and pharyngeal cavities. For this reason, surgical interventions that alter
the anatomy of the tongue and all diseases that restrict its movement
affect speech more or less.
Etiology:
Congenital abnormalities (e.g., ankyloglossia)
Macroglossia due to acromegaly
Minor painful lesions
Neoplastic and non-neoplastic benign lesions
Malignant lesions
Injuries (or surgeries)
Hypoglossal nerve paralysis
Symptomatology:
Almost all speech sounds mainly articulated in the second and third zones are
affected.
Lesions related to the tongue tip or lamina affect consonants, whereas those
related to dorsum and radix affect vowels and resonance.

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Palatal and Velar Dysglossia

Synonym: Velopharyngeal insufficiency
Articulation and resonance disorders resulting from palatal and velar
problems:
Etiology:
Congenital anomalies: Cleft palate, short velum, and deep pharynx
Injuries: Maxillofacial traumas
Surgical: Tonsillectomy, adenoidectomy, sleep apnea surgery, and radical
surgeries for malignancies
Peripheral vagus paralysis
Symtomatology:
The main problem is hypernasality.
Articulation errors:
Obligatory errors: Due to abnormal structure (e.g., audible nasal air emission, nasal
substitution)
Compensatory errors: Errors occur when placement of production is altered in response to
abnormal structure. Manner of production is maintained but placement is changed.

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Nasal Dysglossia
Articulation and resonance disorders resulting from
nasal problems and space-occupying lesions of the
nasopharynx:
Etiology:
Congenital anomalies: Choanal atresia, nasal
glioma/encephalocele
Developmental/traumatic deformities: Deviated nasal septum
Inflammations: Common cold, allergic rhinitis
Non-neoplastic mass lesions: Nasal polyps, turbinate
hypertrophy, adenoid vegetation
Neoplastic lesions: Benign or malign tumors
Symptomatology:
The main problem is hyponasality
Also, nasal consonants are affected: The [m] consonant
sounds like [b], [n] like [d], and [] like [g].

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Pharyngeal Dysglossia
Resonance disorders resulting from pharyngeal problems.
Do not affect articulation (except pharyngeal consonants such as in
Arabic)
Etiology:
Congenital abnormalities: Ectopic thyroid
Neoplastic and non-neoplastic benign lesions (e.g., tonsillar
hypertrophy)
Malignant neoplasms:
Mass effect
Surgical excision
Inflammations: Tonsillitis, pharyngeal abscesses
Scars
Symptomatology:
Isolated pharyngeal dysglossia causes oropharyngeal resonance
problems, such as hot-potato voice, throatiness and stridency.

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Diagnosis
Should include the following steps:
Medical history
Physical examination: Including ENT, neurological and
orthodontic
Perceptual evaluation of speech
Acoustic and aerodynamic analyses
Registration of further physiological parameters:
Electromyography (EMG), electropalatography (EPG),
electromagnetic articulography (EMA)
Radiological examination: Ultrasound, videofluoroscopy,
magnetic resonance imaging (MRI), computed
tomography (CT)

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Acoustic Analysis of Speech

Sounds
Speech sounds consist of voicing energy and noise, which are filtered in
the vocal tract.
Voicing energy: Vowels and consonants
Fundamental frequency (F0)
Formants (from F1 to F5) and related measurements
Voice-onset time (VOT)
Intensity
Duration
Noise: Consonants (and certain pathological vowels)
Spectral peak location
Spectral moment measurements
Intensity
Duration
These parameters can be measured by using the freeware Praat.
Web address: http://www.fon.hum.uva.nl/praat/

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Waveform and spectrogram of the Turkish word [m]:

In the Praat Info window, formants of the first [] vowel
measured at 273rd ms are observed.

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Waveform and spectrogram of the Turkish word [tt]:

VOT value of the first [t] consonant was measured as 51.6 ms.

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FFT of the Fricative [ s ] Consonant at Midpoint and

Measured Spectral Moment Values

Center of gravity = 9 328 Hz

Standard deviation = 1 392 Hz
Skewness = 0.05
Kurtosis = 1.37

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Treatment Modalities
Therapeutic approaches to dysglossias can be
classified as follows:
Medical/surgical procedures
Prosthetic approaches
Behavior-modifying methods:
Non-speech motor exercises
Speech exercises
Total nonverbal communication systems: For severe-
case patients who cannot use oral communication

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Medical/Surgical Procedures
Medical therapy is limited in infectious and allergic
diseases, e.g., stomatitis, acute tonsillitis, and allergic
rhinitis
Surgery: Most dysglossias are treated by surgical
procedures.
Congenital anomalies: Cleft lip, palate, alveolus, tongue tie
Velopharyngeal insufficiencies: Congenital, paralytic, and
iatrogenic (postsurgical)
Benign or malign tumors
Facial paralysis: Static and dynamic reanimation techniques
Certain dental/occlusal problems
Nasal obstructions

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Prosthetic Approaches
Orthodontic prosthesis: For malocclusion and dental
malpositions
Partial or total dental prostheses: For dental loss
Treatment of total or partial edentulous arches requires
dental prostheses: fixed (e.g., bridges and implants) or
removable appliances.
Obturator prostheses: Are generally used to close
openings between oral and nasal cavity after
maxillectomy.
Palatal lift prosthesis: May be used for velopharyngeal
incompetence.

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Behaviour-modifying Methods
General principles:
Early start of treatment aims to avoid maladaptation.
By acquiring compensatory strategies, e.g., a reduced
speech rate, optimizing the use of remaining functions
should be possible.
Necessary modifications of speech behavior cannot be
attained without adequate self-perception, which forms
an essential part of therapy.
Behaviour-modifying methods include non-speech
motor and speech exercises.

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Non-speech Motor Exercises

These methods include relaxation techniques,
range of motion (ROM), and strengthening
exercises.
ROM exercises: Include slow repetitions during
maximum movement of organs.
Strengthening exercises: Include active resistance
against an instrument.
These exercises are used in all speech motor
systems and can be supported by feedback
procedures.

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Speech Exercises
Include all exercises with phonetic and linguistic
content.
It is used to correct compensatory errors.
Speech therapy mainly leads to behavior modifications
following the principle of compensation, indicating that
a continuing disorder is improved by substitution
strategies.
Patients should be instructed to practice errored
speech sounds in all vocalic positions in words and
phrases, focusing on the clearest possible production.
Visual or auditory biofeedback is useful during speech
exercises.

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Prognosis
Good prognosis of speech disorder due to different
kinds of dysglossias is obtained after correction of
organic structures by surgical or orthodontic
procedures.
However, improvement of pronunciation depends
on several factors, such as linguistic abilities, motor
skills, hearing, auditory processing, intelligence,
and motivation of the patient.

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Selected references
Vogel M. (2002). Die Behandlung der Dysarthrie. In: Ziegler W, Vogel M,
Schrter-Morasch H, Grne B, editors. Dysarthrie. 2. Auflage. Stuttgart:
Thieme.
Schrter-Morasch, H., Ziegler, W. (2005). Rehabilitation of impaired
speech function (dysarthria, dysglossia), GMS Current Topics in
Otorhinolaryngology, Head and Neck Surgery, 4: Doc15.
Friedrich, G., Bigenzahn, W, Zorowka, P. (2000). Phoniatrie und
Pdaudiologie (2. Auflage). Bern: Verlag Hans Huber.
Wendler, J., Seidner, W., Kittel, G. und Eysholdt, U. (1996). Lehrbuch der
Phoniatrie und Pdaudiologie (3. Auflage). Stuttgart: Georg Thieme
Verlag.
Ward, E.C., van As-Brooks, C.J. (2014). Head and Neck Cancer:
Treatment, Rehabilitation, and Outcomes (2. Edition) San Diego: Plural
Publishing Inc.

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Thanks for your patience and

attention

This lecture was presented at the 4th Congress of European ORL-HNS:

Cornerstones in European ORL-HNS, in Barcelona, at 7-11 October 2017.

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