SLP ANAPHYS | ARTICULATORY PATHOPHYSIOLOGY

BRIEF REVIEW OF ARTICULATION AND
RESONANCE
a. Articulatory Phonetics
» Articulatory Phonetics or Physiology
Phonetics is the study of the sounds of
language in relation to the physiological
movements that are essential to produce
them.
o Complete Cleft Lip and Palate – upper
lip, palate, and velum
› Clefts in the area before the palate, which
includes the lip and alveolar ridge can occur on
one side (unilateral) or both sides (bilateral).

b. Relating Articulatory Phonetics to Disorders of

Articulation and Resonance
» Structural and functional abnormalities in
speech sound production can be predicted
by understanding anatomical structures and
physiological processes involved.

DEFINITIONS AND ORGANIZATION OF

DISORDERS
Articulation Disorder
› is a physical impairment of the ability to
correctly move and position the articulators for
the correct production of speech sounds.
Phonological Disorder
› involve incorrect production of speech sounds
and violations of the rules that govern the
speech sounds system.
Organic Disorder
› can be traced back to an observable etiology
such as a biochemical aberration, genetic
variation, illness, injury, or neurological
impairment.
Functional Disorder
› exists in the absence of any known or observable
organic pathology.
STRUCTURAL DISORDERS
Cleft Lip and/or Palate
› A cleft occurs when the maxillary bones do not
fuse for embryonic development between the 8th
and 12th weeks.
o Cleft Lip – only the upper lip
o Cleft Palate – only the hard palate
o Cleft Lip and Palate – both upper lip and
hard palate
› Articulation Challenges:
o A cleft in the hard or soft palate can hinder
an individual’s ability to generate enough
intraoral air pressure for producing
pressure consonants like plosives and
affricates.
o This can result in distorted, weak, or absent
production of these sounds.
› Resonance Issues:
o Clefts in the hard and/or soft palate
compromise the separation between the
oral and nasal cavities.
o This can lead to hypernasality, where
non-nasal speech sounds, such as vowels
and most consonants in English, become
heavily nasalized.
o Additionally, nasal air emission may occur
when air exits the nostrils under pressure.
› Compensatory Strategies:
o People with more severe cleft lip and palate
often develop compensatory strategies to
produce pressure consonants and reduce
hypernasality.
o The glottal stop (produced by closing the
vocal cords), and pharyngeal fricative
(created by turbulence in the pharynx) are

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used as replacements for plosive and o shallow orbits (create the appearance of
fricative sounds. protruding eyes)
› Children with cleft palate often have o a beak-like nose
conductive hearing loss due to middle ear o flattened nasal bridge
infections (known as otitis media) caused by
food or drink entering the middle ear through
the cleft.

OTHER CRANIOFACIAL ANOMALIES

Apert Syndrome
› “acrocephalosyndactyly”
› A disorder characterized by skeletal
abnormalities
› Exhibit two prominent features:
a. Unusually peaked head
b. Webbed fingers and/or toes

› Clefting may affect oral-nasal resonance, and

malformation of oral structures can lead to
various articulation errors.

Ectrodactyly-Ectodermal Dysplasia-Clefting
Syndrome
› It affects the mandible and maxilla, leading to a
potentially flat or concave facial appearance and
possible palate deformities, including clefts
› It includes speech sound errors due to
compromised velopharyngeal mechanism
integrity, malformed oral structures, and
hearing impairment
Crouzon Syndrome
› “craniofacial dysostosis”
Pierre Robin Sequence
› similar to Apert Syndrome but is less severe
› in terms of oral structures: small maxilla and a
shorter nasopharyngeal space.
› Additional facial features:
o widely spaced eyes
› Ectrodactyly – deformities in the hands and
feet, where one or more central digits are
missing, giving them a “lobster-claw”
appearance.
› Ectodermal Dysplasia: a paucity of body hair,
dry skin (due to the absence of sweat glands),
and missing or malformed nails and teeth.
› Cleft lip and palate are common characteristics
› Some may experience conductive hearing loss
› Difficulty generating enough intraoral air
pressure for producing certain speech sounds,
especially pressure consonants.
› Hypernasality and nasalization of non-nasal
speech sounds
› Dental anomalies and other oral variations:
speech sound errors
› Not classified as a syndrome due to the absence
of a clear genetic cause.
› Developmental issue during fetal growth where
the mandible doesn’t grow properly.

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› Tongue remains “high” in the oral cavity,
preventing the palatal shelves from elevating
and fusing.
› Typically results in a U or V-shaped cleft palate.
› Often accompanied by habitual posterior
displacement of the tongue into the pharynx:
lead to upper airway obstruction and
swallowing difficulties
Stickler Syndrome
› “congenital progressive arthro-opthalmopathy”
› Encompasses many signs and features seen in
Pierre Robin sequence, including clefting of the
palate.
› Involve additional health issues affecting the
joints (arthritis and skeletal abnormalities) and
visual system (astigmatism, cataracts, detached
retinas, and severe myopia).
› Difficulties in oral-nasal resonance during
speech.
› In severe cases: employ unusual articulatory
strategies
Velocardiofacial Syndrome
› Most common craniofacial syndrome associated
with clefting.
› Common features:
o Cardiac problems
o Distinct facial characteristics
▪ Prominent nose
▪ Long face
▪ Recessed chin
▪ Microcephaly (small head)
› Velum may have a cleft or congenital
velopharyngeal incompetence, resulting in
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hypernasality or highly nasalized non-nasal
speech sounds.
› Individuals may use compensatory articulatory
substitutions like the glottal stop and
pharyngeal fricative to enhance speech clarity.
OTHER STRUCTURAL ANOMALIES
Velopharyngeal Incompetence Not Related to
Craniofacial Anomalies
› Caused by short soft palate or deep/wide
nasopharyngeal gap, preventing proper seal
against pharyngeal wall.
› May occur congenitally in the absence of
craniofacial anomalies.
› In terms of speech production, the result of
thing is similar to what you expect for cleft
palate—hypernasality.
› In some cases, this may be a result of having a
hard palate that is too short.
› In many cases, the muscles that mediate
movement of the soft palate may insert into the
hard palate instead of the anterior portion of the
soft palate.
› In some cases, there may be neurological
damage to either the nerves or muscles that
control movement of the velum so that it cannot
elevate to meet the posterior pharyngeal wall.
Glossectomy
› In most severe cases, the individual with tongue
cancer will require this surgical procedure that
removes all or part of the tongue.
› The tongue in involved in the production of all
the vowels and diphthongs and 75% of the
consonant sounds in English.
› Partial tongue removal can aid in improving
articulation and resonance of error speech
sounds and diphthongs and vowels through
compensatory strategies.
› Minor surgery can potentially restore a patient’s
speech production to its premorbid level in
some cases.
› With total glossectomy, however, expect
pervasive articulation errors involving
practically the entire speech sound system as
well as poor resonance of the diphthongs and
vowels.
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› The speech sound system may be so adversely ▪ Altered taste

affected that the patient’s speech is highly ▪ Speech difficulties
unintelligible. ▪ Drooling on the affected side
› In these cases, the only option may be to provide ▪ Eyelid and mouth drooping
an augmentative and alternative ▪ Dryness or excessive tearing in the
communication (AAC) system for the affected eye
individual. ▪ Heightened hearing on the affected side
› AAC systems may include gestural
communication such as Amer-Ind or manual
signs; basic communication displays with
alphabetic letters, words, or symbols on them;
or electronic devices that produce synthetic
speech output.

NEUROLOGICAL DISORDERS
Cranial Nerve Damage
a. Damage to the Trigeminal Nerve
› Trigeminal neuralgia, also known as “tic
doulourex”
› Characterized by severe, sharp facial pain,
typically around the jaw area.
› The cause of this disorder is not fully
understood, but it may be due to
degeneration of the trigeminal nerve or by
pressure places upon it by inflammation or
some other source.
› Pain episodes can last from several minutes
to several hours and can be triggered by
smiling, chewing, blowing the nose, or
brushing teeth.
› It affects jaw movement, impacting chewing
and speech.
› Unilateral damage causes jaw deviation,
while bilateral damage can lead to an
inability to open or close the jaw, affecting
speech sounds like bilabials, interdentals,
and labiodentals.
› Oral resonance and high anterior speech
sounds may also be affected.
b. Damage to the Facial Nerve
› Bell’s Palsy – neuropathology associated
with the facial nerve, causing unilateral facial
paralysis
› Exact cause is unknown, but a virus, such as
herpes simplex, is suspected.
› Symptoms:
› Unilateral damage has milder effects on
speech and swallowing than bilateral
damage.
› Specific facial muscles involved in lip
movement are important for speech sounds
like bilabials and labiodentals and for
swallowing.
› Damage to the facial nerve may disrupt
swallowing, potentially causing food and
drink to eject from the mouth during
swallowing attempts and drooling.
c. Damage to the Glossopharyngeal Nerve
› The glossopharyngeal nerve innervates only
one muscle involved in swallowing, the
stylopharyngeus—this muscle plays a part
along with several other muscles to dilate,
elevate, relax, and tense the pharynx.
› For there to be any measurable effect on
resonance or swallowing, the vagus nerve,
and possibly the spinal accessory nerve as
well, would have to be damaged along with
the glossopharyngeal nerve.

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d. Damage to the Vagus and Spinal Accessory
Nerve
› The vagus and spinal accessory nerves work
together to innervate the muscles in the head
and neck, but the vagus nerve also innervates
some muscles that the spinal accessory nerve
does not, such as the muscles of the soft
palate and pharynx.
› Damage to the vagus nerve is more likely to
affect the soft palate and pharynx than the
tongue.
› The vagus nerve has a branch called the
pharyngeal branch, which supplies the
soft palate and pharynx.
› Damage to the vagus nerve below the level of
the pharyngeal branch will affect the larynx,
while damage to the pharyngeal branch alone
will not affect the larynx.
› Damage to the pharyngeal branch of the
vagus nerve can cause diminished movement
of the soft palate and pharynx.
› This can lead to hypernasality, difficulty
swallowing, and muffled speech.
› Damage to the vagus nerve is unlikely to have
a significant effect on articulation.
e. Damage to the Hypoglossal Nerve
› The hypoglossal nerve is the 12th and final
cranial nerve. It is a motor nerve, meaning
that it controls muscle movement. The
hypoglossal nerve controls all of the muscles
of the tongue except the palatoglossus.
› Damage to the hypoglossal nerve can cause a
variety of problems, including:
o Dysarthria (difficulty speaking)
o Dysphagia (difficulty swallowing)
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o Tongue Atrophy (wasting of the
tongue)
o Tongue Fasciculations (twitches of
the tongue)
› Speech:
o The tongue is essential for speech.
o By moving the tongue into different
positions, we can produce different
sounds.
o Damage to the hypoglossal nerve can
make it difficult or impossible to move
the tongue, which can lead to dysarthria.
› Chewing:
o The tongue helps to move food around
the mouth during chewing.
o Damage to the hypoglossal nerve can
make it difficult or impossible to chew
food properly.
› Resonance:
o The tongue helps to shape the sound of
vowels and diphthongs.
o Damage to the hypoglossal nerve can
lead to problems with resonance, which
can affect the quality of speech.
› Swallowing:
o The tongue helps to push food back into
the throat for swallowing.
o Damage to the hypoglossal nerve can
make it difficult or impossible to swallow
properly, which can lead to dysphagia.
MOTOR SPEECH DISORDERS
› A motor speech disorder is the result of a
neurological impairment in which motor
planning, programming, neuromuscular
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control, or the execution of speech is adversely
affected (Duffy, 2005).
› The more common etiologies of this condition
are cerebrovascular accident (i.e., stroke),
degenerative disease, traumatic brain injury,
and neoplasm.
› In the majority of cases of dysarthria, several
cranial nerves may be involved or the damage
may be more diffuse as the site of lesion tends to
be more central.
Apraxia of Speech
› is a central nervous system disorder with
damage originating in the language-dominant
cerebral hemisphere.
› You are more likely to observe a patient with
AOS also having aphasia.
› In terms of speech production, one could think
of AOS as a “short circuit” in the brain’s ability
to program the articulators for correct speech
sound production.
› For a person with AOS, speech sound errors
primarily involve the consonants, but in some
cases may involve vowels as well.
› Errors typically involve distorted sound
substitutions, omissions of sounds, and to a
lesser degree sound transpositions.
› A patient with AOS will relatively have relatively
few articulatory errors when producing
utterances of low linguistic complexity, but
errors tend to increase considerably as the
linguistic context gets more complex (e.g.
producing longer sentences or saying words of
increasing syllable length)
› Prosody - tends to be adversely affected in
AOS.
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Dysarthria
› Site/s of lesion - cerebral cortex, the
subcortical region of either hemisphere, the
cerebellum, the brainstem, and/or the
periphery (i.e., the cranial and/or spinal nerves)
› Types of Dysarthria:
o Ataxic
o Flaccid
o Hyperkinetic
o Hypokinetic
o Spastic
o Unilateral UMN (UUMN)
o Mixed
› Typically involves every component of speech
production—respiration, phonation,
articulation, resonance, and prosody.
› Compared to AOS, dysarthria has impaired
range of movement and strength of the
articulators.
› There tends to be no periods of error-free
speech.
› Both consonants and vowels are affected.
› Articulation errors include distortions and
omissions of speech sounds.
› In many cases, the patient exhibits imprecise
productions of consonants.
› Speech may be slow and slurred.
› Automatic and volitional speech tend to be
equally affected, and speech sound errors tend
to be consistent regardless of linguistic
complexity.
OTHER NEUROLOGICAL DISORDERS
Progressive Neurological Disorders
› Worsens over time
› Fatal (in many cases)
Nonprogressive Neurological Disorders
› Do not get worse over time
› The patient develops the disorder at some point
but symptoms remain constant across the life
span.
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PROGRESSIVE NEUROGICAL DISORDERS
ALS / LOU GEHRIG’S DISEASE
› fatal neuropathy characterized by the
degeneration of both upper and lower motor
neurons.
› loss of voluntary muscle activity and muscle
atrophy as neural impulses to muscles are
disrupted.
› Exact cause: unknown
› slightly more common in men, typically
occurring between ages 40 and 60.
› Initial Symptoms: muscle weakness,
twitching, cramping, and stiffness, often in the
limbs.
› Later stages affect the respiratory muscles,
leading to respiratory failure or pneumonia.
› involves both the central and peripheral
nervous systems due to the damage to both
upper and lower motor neurons.
› It causes a mixed dysarthria, combining flaccid
and spastic characteristics, resulting in speech
issues like hypernasality, nasal air emission,
imprecise articulation, slow speech rate, and
vowel distortions.
› Swallowing problems are common, especially in
advanced stages, with specific symptoms
varying among individuals.
MS / Multiple Sclerosis
› An autoimmune disorder where the immune
system attacks the central nervous system,
leading to the loss of myelination in the
myelinated axons of neurons.
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› More common in women and usually occurs
between ages 20 and 40, although cases can
happen later.
› Specific cause of MS is unknown, but some
suspect a viral origin.
› Symptoms:
o Chronic Fatigue
o Sensory Disturbances (burning, itching,
numbness, tingling)
o Visual Issues (double vision, decreased
color perception, reduced visual acuity).
› Multiple - refers to the demyelination that can
occur in various parts of the CNS
› Sclerosis - breakdown of myelin creates scar
tissue along the axon
› MS-related dysarthria can vary—it often
manifests as a mixed type with characteristics of
ataxic and spastic dysarthria
› Imprecise articulation leading to slurred speech
and tongue "overshooting" during articulation
are common speech characteristics in
individuals with MS, giving the impression of
intoxication.
Parkinson’s Disease
› A central nervous system neuropathy affecting
the basal ganglia in the cerebral hemispheres.
› Results from reduced dopamine production,
leading to decreased stimulation of the motor
cortex and causing symptoms:
o Bradykinesia – slowed movement and
speed
o Masked facies
o Muscle rigidity
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o Shuffling gait
o Stooped posture
o Tremors
› Higher prevalence in men
› Possible causes includes toxins, head trauma,
and idiopathic factors (unknown).
› Speech and resonance issues often involve
imprecise consonants due to articulatory
undershooting and hypernasality.
› Individuals may experience difficulty initiating
speech, rapid, unintelligible speech
(mumbling), and palilalia (involuntary
repetition of words or phrases during speech)
› Swallowing problems are common
NONPROGRESSIVE NEUROGICAL DISORDERS
Cerebral’s Palsy
› One of the most common nonprogressive
neurological disorders and the most prevalent
developmental motor impairment.
› Results from central nervous system (brain)
injury occurring before, during, or soon after
birth.
› There are several types of CP: spastic (50% of
cases), athetoid (20% of cases), ataxic (10% of
cases), and mixed types (20%).
› Speech production disturbances in CP can affect
the respiratory, phonatory, articulatory, and
resonance systems.
› Spastic CP
o Reduced vital capacity, resulting in
inadequate breath support for speech and
hypernasality due to velopharyngeal
incompetence.
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o Speech is often slow, laborious, and marked
by imprecise articulation.
› Athetoid CP
o Irregular breathing patterns, aphonia in
severe cases, and strained and strangled
phonation in milder cases.
o Mobility issues in the soft palate cause
hypernasality, and articulation is
characterized by exaggerated jaw
movements and limited tongue
movements, leading to consonant and
vowel distortions.
› Ataxic CP
o Speech characteristics typical of ataxic
dysarthria, including shallow inspiration,
lack of expiratory control, imprecise
articulation, inconsistent sound
substitutions and omissions, and poor
rhythm and reduced prosody.
o Oral-nasal resonance is usually unaffected
in ataxic CP.
SENSORY DISORDERS
Hearing Impairment
› Speech production is monitored through
auditory, tactile, and kinesthetic modalities.
› Auditory feedback, primarily through air
conduction and bone conduction, is vital.
› Bone conduction provides feedback via
vibrations in the skull, creating a unique
perception of one's voice.
› Hearing loss can disrupt speech monitoring.
› Severe hearing loss can prevent individuals
from accurately perceiving their speech sounds.
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› Tactile and kinesthetic feedback are secondary
to auditory feedback in speech production.
› Hearing loss severity is categorized as mild,
moderate, severe, or profound.
› Configuration relates to which sound
frequencies are most affected, such as high
frequency, low frequency, or sloping hearing
loss.
› Severe hearing loss, especially in mid-
frequencies, can significantly impact speech
production.
› Approximately 1450 individuals per 100,000
are deaf.
› Roughly 1 in 1000 infants is born with profound
hearing loss.
Types of Hearing Loss
› Central
▪ Central hearing loss results from damage to
the central nervous system, where the
hearing mechanism remains intact, but the
neural signal doesn't reach the auditory
cortex due to brain damage.
› Conductive
▪ Conductive hearing loss affects the outer or
middle ear, causing a hindrance in the
transmission of sound to the inner ear.
▪ This type of hearing loss can often be
reversed.
▪ For instance, if it's due to an ear infection
like otitis media, antibiotics can clear the
infection, restoring normal hearing.
▪ Likewise, damage to the small middle ear
bones (ossicles) can be repaired with
reconstructive surgery, leading to a return
to normal hearing.
› Mixed
▪ A mixed hearing loss involves both
conductive and sensorineural components.
While the conductive loss can be addressed,
the sensorineural loss is usually permanent.
› Sensorineural (Inner Ear)
▪ Sensorineural hearing loss, in contrast, is
permanent.
▪ It occurs when the hair cells in the cochlea,
vital for converting middle ear mechanical
energy into neural impulses sent to the
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brain via the acoustic nerve, are irreparably
damaged, or there is an issue with the
acoustic nerve itself.
Effects of Hearing Loss on Speech
› Speech Sound Errors – Individuals with
speech disorders may exhibit various errors,
including substitutions (replacing one sound
with another), omissions (leaving out sounds),
and distortions (altering the intended sound).
› Oral and Nasal Consonants – Some
individuals may have difficulty distinguishing
between oral consonants (sounds produced
with airflow through the mouth) and nasal
consonants (sounds produced with airflow
through the nose), leading to errors in
pronunciation.
› Plosives and Fricatives – Substituting
plosive sounds (e.g., /p/, /b/, /t/, /d/, /k/, /g/)
for fricative sounds (e.g., /f/, /v/, /s/, /z/, /ʃ/,
/ʒ/) or liquids (e.g., /l/, /r/) can result in speech
sound errors.
› Voiced and Unvoiced Consonants – An
inability to distinguish between voiced (vocal
cords vibrate during sound production) and
unvoiced (vocal cords do not vibrate)
consonants can lead to speech sound errors.
› Vowel Neutralization – Neutralization of
vowels may occur when distinct vowel sounds
become indistinguishable in the speech of an
individual with a speech disorder.
› Cul-de-Sac Resonance – Cul-de-sac
resonance refers to a flat or muffled voice
quality, often caused by an obstruction in the
vocal tract or nasal passages.
› Denasality – Denasality refers to a speech
condition where there is a lack of appropriate
nasal resonance when producing nasal sounds
(e.g., /m/, /n/, /ŋ/).
› Poor Coordination – Individuals with speech
disorders may experience poor coordination
between respiration (breathing), phonation
(voice production), and articulation (speech
sound formation). This can result in reduced
vocal intensity, unusual stress and intonation
patterns, and atypical phrasing in speech.
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