The American Academy of Otolaryngology and Head and Neck Surgery definition:
‘Vocal fold (or cord) paresis and paralysis result from abnormal nerve input to the voice box muscles (laryngeal muscles). Paralysis is the total interruption of nerve impulse, resulting in no movement; paresis is the partial interruption of nerve impulse, resulting in weak or abnormal motion of laryngeal muscles.’

The causes of ‘abnormal nerve input’ or damage to the recurrent laryngeal nerve are numerous. The recurrent laryngeal nerve is the specific branch of the nerve which controls all (but one) of the intrinsic laryngeal muscles. Because of the course of the nerve, particularly the left nerve which descends into the chest before reaching the neck, it is susceptible to injury. Any surgery to the neck or chest which takes place near the course of the nerve can result in damage to nerve function. The likeliness of recovery is very much dependent on how badly the nerve has been damaged i.e. bruised or severed completely. Knowing this information can help ENT doctors and Speech and Language Therapists plan treatment. Other reasons for the vocal cords not functioning normally may be neurological (e.g. a tumour in the brain) or idiopathic (no clear cause). It is often the case that the cause cannot be identified, and may be viral.

The main clinical symptom would be of a breathy and changed voice quality. The quality is very much dependent on the extent of damage and the position of the cord which is not mobilising. This symptom can be rather concerning for people because voice is a big part of our character. Aside from voicing, the vocal cords also have a protective function. They come together to build up pressure under the cords to enable strong coughing and they also come together whilst swallowing to close the airway off and protect the lungs from food and drink going the ‘wrong way’. Coughing is an important protective mechanism which can be reflexive or volitional. If the vocal cords do not close the airway sufficiently during swallowing then people may begin to experience difficulty with swallowing. This may include coughing or chestiness. In our experience we have found that the degree of swallowing difficulty is very variable and the severity of the vocal cord dysfunction does not always correlate with the severity of the swallowing difficulty.

Speech and Language Therapists assess, advise and treat people who are experiencing difficulty with their voice and swallowing as a result. There are surgical options however it is always advisable to trial voice therapy exercise first as all surgery carries some risk. In some cases people need to have combination of voice therapy and surgery.

From a voice perspective the impact of a palsy is very much dependent on the individual. For example a singer would be hugely affected by the slightest change in there voice however an individual who lives alone and tends not to communicate verbally may not be so concerned about voice change. At Speakology we prioritise individualising care plans.

A recent case involved a teacher who underwent thyroid surgery which resulted in vocal cord paralysis. A small number of patients undergoing thyroid surgery do experience this complication. One cord was paralysed. Voicing was achievable but breathy and speaking at length was tiring. We agreed with ENT that surgery was not indicated and that vocal cord movement would resume. Voicing was possible because of the resting position of the weak cord however he patient was experiencing voice loss and discomfort in the throat at the end of the day. Through assessment and thorough history taking we identified that the patient was developing a muscle tension dysphonia on top of the organic dysphonia they were experiencing. A detailed therapy package was put in place which worked on easy voicing as well as vocal cord adduction (the cords coming together). The patient made a full recovery approximately nine months later.

We have experienced a great deal of success with this client group through close working with ENT colleagues. Contact us to find out more about voice therapy.

We have been working with clients with a diagnosis of Multiple Sclerosis (MS) for many years. Find out more about MS here

Symptoms might include fatigue, visual problems and difficulties with walking, but MS is different for everyone.

click here for a lovely article on real experiences of speech difficulties in MS

People with MS-related speech symptoms report slurred or indistinct speech; a quiet or weak voice, changes to voice quality (e.g. nasal, hoarse or breathy); change in pace of speech; and speech that sounds monotonous and lacks emphasis or rhythm. Speech disorders caused by weakness of muscles are collectively known as dysarthria.

Like all of the other symptoms of MS, speech and swallowing difficulties can become more pronounced when tired. This can be alleviated in practical ways such as ensuring main meals and long conversation are minimised during times when one is fatigue.

We have found that dysarthria is more responsive to strategies than strengthening oromotor exercises (exercises for the muscles of face, mouth and throat) which result in fatigue. There is sometimes a role for exercises e.g. strengthening voice/coughing but we are acutely aware that exercise programmes need to be tailored and regularly reviewed in detail. In severe cases of dysarthria we can look at alternative and augmentative ways of communicating.

Sometimes individuals can experience cognitive and language changes. This may result in difficulty formulating sentences or finding words. This can be a frustrating issue both for the person with MS and friends/family. Speech and Language therapy can help to address these issues.

The ability to swallow safely may be affected in moderate or severe stages of MS. We have worked with many families to talk through their symptoms and offer practical advice on how to manage these difficulties.

Today I assessed a lady who had been admitted to hospital with a chest infection. At the time of admission she was too unwell to eat and drink but now that she has recovered from her acute illness we had the opportunity to think about her nutrition options. She decided that she would like to eat small amounts but receive the main bulk of her nutrition via a gastrostomy. It is often difficult for people to make decisions about their nutrition without a full picture of their swallowing abilities and swallow prognosis.

Contact Speakologyslt on 02036332499 to find out more about how we can help you or your family member/client.

The ability to swallow is something we all take for granted. So imagine the catastrophic effects of not being able to swallow safely and comfortably (dysphagia). Being unable to swallow hugely impacts one’s ability to socialise. Let us think back to the last time we met friends or family or arranged to meet someone. Usually most social gatherings involve eating and drinking: meeting up in a pub, going out for dinner, throwing a party, having friends over in the summer for a barbecue. As George Bernard Shaw once said ‘There is no love sincerer than the love of food’. Swallowing difficulties can make one feel excluded from many social activities. Eating and drinking is more than just sustenance- a fact.

Swallowing is a complex behaviour which can be volitional or reflexive. It involves more than 30 muscles. The swallowing process is commonly divided into oral (mouth), pharyngeal (neck), and oesophageal (gullet) stages.

It can be devastating to be given the news that you or your loved one is unable to swallow safely or that their diet is to be limited to certain consistencies or types of food. At Speakology we feel that swallow rehabilitation is an underutilised. Although all dysphagias cannot be resolved there are certainly many that can be reduced or resolved. This can only be done with targeted and specialist therapy. We like to think of dysphagia therapy as physiotherapy for the mouth and throat. By applying exercise principles to therapy it is possible to drive muscle change or even recruit more intact muscles to compensate. The main challenge of therapy, in our experience, is targeting the small muscles in the mouth and neck and this is more taxing than exercising limbs, but there are novel and downright strange ways of achieving this if one is determined enough!

If you or someone you know is suffering from dysphagia ask your Speech and Language Therapist about therapy options or contact Speakology on 02036332499.

We have a huge deal of experience in providing therapy for people with language disorders following stroke. As therapists, we have applied our expertise in numerous settings including the public and private sector. Furthermore we have provided therapy in acute and rehabilitation wards and also at home. What has taken us aback is the variability in service provision throughout the southeast. This is a difficult issue to address given the variability and lack of research around the amount, intensity and timing of therapy. This article click here addresses very well the ongoing discussion about timing of aphasia therapy. At Speakology we believe that timing of therapy, although worth taking into consideration, should not be the main focus of therapy. Instead the emphasis should be placed on providing goal-bound and high quality therapy. Here are some examples of SMART (Specific, Measurable, Achievable, Relevant/Realistic, Time-bound) goals that we have achieved with our clients:
– By the end of session four Mr S will be able to say the name of two family members to gain their attention without prompting
– By the end of session six Mr N will be able to order Cappucino at the coffee shop without prompting and support from Mrs N
– By the end of session six Mr N will be able to speak to his cousin in Gibralter over the phone and ask about how he is and what he has done during the week using a written prompt sheet

We specialise in working with clients and their families to set realistic and functional goals for therapy. We provide carry over and maintenance tasks to be completed between sessions and after therapy blocks to maintain and expedite recovery. Speech and language therapy in aphasia is not an exact science and this is not surprising as no two strokes or people can ever be exactly the same. Through thorough assessment and fact-finding an effective therapy programme can be developed to meet the needs of the client. Visit www.speakologyslt.co.uk for more information.

I have been running a communication group for clients with a diagnosis of Huntington’s disease for three years. The goals of the group started out very clinical: to get individuals to use the assistive technology devices, to focus on memory and language based tasks and to identify speech strategies to maximise clarity. I must now confess to forgetting the most important part during the early days of the group: to get to know each other and chat. Participants spoke of where they had travelled, their likes/dislikes, revealed family secrets, got very political during the elections and had the opportunity to socialise. The lesson: you can’t have an enjoyable and effective communication group without incorporating real life experiences, communication and conversation into the fabric of the group. It is possible to work on speech therapy goals whilst having fun. I shelved the therapy exercise book and moved to making therapy about real experiences and conversation. What we like to cook, recalling the ingredients, recalling where we’ve holidayed, why we didn’t like certain people, debated controversial tropics, talked about our fears, reflected on all the jobs we have done and all of the people we have met. All this real dialogue occurred whilst working on our communication skills and practicing using our assistive and augmentative communication devices. The members of the groups may have changed over time but the group is going strong.

Group therapy is a fantastic way of consolidating work done in individual therapy. If you would like to find out more then contact Speakology on 02036332499. Find out more about Huntington’s Disease at http://hda.org.uk/

Bindu Vekaria

This seems to be something of a ‘hot topic’ at the moment, which brings about a huge amount of controversy. You may have heard and read many different articles with different points of view, and i am sure you have your own. As a Speech Therapist I deal with many people who are either in the palliative phase of their life, or being controlled by a progressive disease. Enabling someone to maintain their dignity and quality of life is something I feel incredibly passionate about. I would like to describe a situation that as Speech Therapists we may find ourselves in, which will contribute heavily to someones quality of life in their final phases of life.

A common situation that comes about for a Speech Therapist is when you visit someone with advanced dementia who has a swallowing disorder (dysphagia). This means that there is problem with their swallowing, and there may be a risk that food or fluid could go down the wrong way to the lungs, rather than stomach. Complications of something going down the wrong way can be chest infections, pneumonia, choking and even death. But having said this, some people are able to tolerate things going ‘down the wrong way’ and do not suffer said complications. It is understood that the risk may be reduced if someone is mobile, independently able to feed themselves, and has good oral care.

It may be that the person has had a swallowing assessment, and no benefit was found from modifying their food and fluid, strategies were not able to be deployed, and specialist equipment were of no benefit. Therefore, concludes that the risk of things going down ‘the wrong way’ cannot be eliminated.

When someone has a swallowing disorder they may or may not be aware of it. There are obvious signs such as coughing, choking, eye watering and dribbling of food/fluids. But they may also be quite unaware, and show no obvious signs.

Now, in this situation, you have two choices :

Accept the risk that food/fluid may go down the wrong way and allow that person to continue eating and drinking, given that it may be one of the few things that they enjoy and provides them with an improved quality of life. In this case, as a Speech Therapist I would provide recommendations of what is ‘safest’ to eat and drink, and provide any strategies that may be of benefit.
Place them nil by mouth, and insert a permanent feeding tube in their stomach. This would mean that they no longer eat or drink anything, are no longer taking part in the social activity of meal times that break up the day, and have a foreign object inserted in them, which they may or may not understand.

These are obviously very complex decisions to make, which consider many other factors, and not decisions we make alone, but with the input from the medical team, patient and family. But it poses an interesting question of whether we accept a risk to improve quality of life, or eliminate risk but certainly restrict quality of life.

I feel that from my experience, a persons viewpoint may be different if you were to ask this question generally, and if then again if a person’s close family member were to find themselves in this situation. Many people feel that they do not want to prolong suffering, and to allow their loved one to enjoy the time they have left. Other people may only see one goal : keeping a family member alive at any cost.

There has been many well documented cases of people wanting to die with dignity.

For example, you may remember a well publicised legal fight for Tony Nicklinson who suffered a stroke and consequently locked in syndrome. This usually means that you are completely paralysed and unable to speak or move, but remain conscious and able to think and reason. You may be able to move your eyes, and often this is used as a method of communication.

He reported that he found life ‘dull, miserable, demeaning, undignified and intolerable’. He appealed to the courts to end his life, but was consequently denied, causing devastation to himself and family. In his final days, he contracted a pneumonia, refused to eat and drink and denied treatment which ultimately led to his death. This was very likely a very unpleasant and devastating way to die. To read more in depth, visit http://www.dailymail.co.uk/news/article-2191944/Locked-syndrome-victim-Tony-Nicklinson-dies-aged-58-refusing-food-contracting-pneumonia.html.

Another more recent well publicised example was that of Brittany Maynard who at 29 discovered she had an aggressive brain tumour. She was young, newly married and planning to have a family when she learnt the news. She was given six months to live, and was advised to have full brain radiation, which comes with a long list of side effects. She is reported to have deliberated this with her family and after deciding that because there was no curative treatment, and the time that she had left would be depleted of any quality, she chose to end her life, to maintain her dignity.

She and her family were forced to move to Oregon, which is currently 1 of 5 states in America that has authorised death with dignity for terminally ill patients. She was able to collect the medication that would end her life when she chose, and take it when she felt ready, in the company of those she loved and choise. This enabled her to maintain her dignity, and not suffer for weeks, or months as her body began failing, leaving her family to watch her slowly dying. To read more, follow http://www.independent.co.uk/news/world/americas/us-woman-brittany-maynard-explains-why-shes-choosing-to-die-on-1-november-9784119.html

To read more on this subject and find out how you can support this campaign in England, please visit http://www.dignityindying.org.uk

For advice and help on enabling your relative maintain their quality of life, and how to make communication and eating and drinking more comfortable, please get in touch at www.speakologyslt.co.uk

What is Speech and Language Therapy? When I speak to friends who know very little about the profession they allude to stammering, lisps and working with children. My confession is that when I enrolled on my degree course this was also the view of Speech and Language Therapy that I held. I imagined myself working in a clinic doing sound therapy/ phonology work with a parent by my side, bribing a child with stickers and convincing them to place their tongue a little further back when saying their ‘s’. I then found myself drawn to working with adults with acquired speech and swallowing difficulties. As a student I worked with an adult therapist who would assess adults with swallowing difficulties and was amazed to see the difference her input made. We worked with a gentleman with Parkinson’s disease and her advice helped him enjoy eating and drinking again. She was able to recommend safe diet consistencies (ie foods that would not result in coughing and distress and put the patient at risk of choking/ developing a chest infection due to food ending up in the lungs), give advice about timing of meals in relation to medication, advise on suitable cutlery, reassure and support his wife,and overall make his mealtime experience what it should be- enjoyable.

We have since worked with many people with speech and swallowing difficulties caused by Parkinson’s and have developed good working relationships with specialist Parkinson’s nurses and neurologists.

We are trained to provide the evidence-based gold standard therapy: Lee Silverman voice therapy. Find out more here: http://www.lsvtglobal.com/patient-resources/what-is-lsvt-loud

It is rare to meet people who are aware of the field of adult Speech and Language Therapy unless they or a friend family have received therapy. If you or someone you know is suffering from difficulty with swallowing or communicating then contact Speakology on 0203 633 2499 and you may be surprised to find that there are solutions that can improve or resolve the issue.