Evaluation of articulation and resonance: Age 3 and beyond

Tara L. Whitehill University of Hong Kong ACPA-ASHA Pre-Conference Symposium Philadelphia, April 2008

Aspects of communication “at-risk” in children born with cleft palate • Articulation • Resonance

• Language • Hearing • Voice • “Sociocommunicative competence” (Peterson-Falzone et al., 2001)

Key Questions

when evaluating articulation/ resonance in child with cleft palate • Is speech (articulation, resonance) WNL or not?

• If not WNL, is the speech disorder cleft related (or due to some other cause)?

• If cleft-related, what are possible contributing factors?

• How can I best evaluate articulation and resonance for a child with cleft palate?

Resonance disorder

• •

Not a voice disorder Not an articulation disorder

• Hypernasality • Hyponasality • Mixed resonance disorder

Hypernasality

• Excessive nasal resonance during the production of speech • Affects vowels and vocalic consonants.

– moderate/severe hypernasality => nasalization of oral consonants • Related to abnormal coupling of oral and nasal cavities – oral consonants, vowels require separation between oral and nasal cavities. – VPI, O-N fistulae, unrepaired cleft => impaired oral-nasal closure => hypernasality.

• Continuum with wide range of normal

Hyponasality

• Reduction in normal nasal resonance • Insufficient nasal airflow during target nasal sounds • Generally caused by blockage in the nasopharynx or obstruction in the nasal cavity • particularly affects nasal phonemes (e.g., /m/=> [b]; /n/ => [d]).

Cul-de-sac resonance

• Type of hyponasality • Anterior nasal obstruction • “Muffled” quality

Mixed resonance disorder

• Hypernasality and hyponasality co-exist • Not uncommon in cleft palate population • Hyponasality can mask hypernasality

Possible causes: resonance disorder

• Hypernasality – Structural: esp. VPI – Functional: physiological e.g dysarthria – “learned” (hx VPI -- or not) – Non-cleft VPI: congenital VPI; VP dysproportion; dysarthria • Hyponasality – Usually structural: polyp, deviated septum, other nasal airway structural abnormalities, allergic rhinitis

How to evaluate resonance?

• Perceptual judgement: gold standard • Problem: experience, reliability • Training/educational materials – McWilliams & Philipps (1990) audiotape – Kuehn et al. (2002) speech samples http://www.acpa-cpf.org/EducMeetings/speechSamples/index.htm

• Need to “calibrate” -- with others or with self

Speech materials

• Sustained vowels, CV syllables, single words, sentences, conversational speech • High vs. low pressure consonants • High vs. low vowels • Oral vs. nasal consonants • Note consistency, variability

How to rate resonance?

• Simple to complex – Normal vs. abnormal – Hypernasal, hyponasal, mixed – Severity (mild, moderate, severe) – Consistency

Rating scales (examples)

Hypernasality ________________________________________ 1 2 3 4 normal mild moderate severe Hyponasal Normal Hypernasal _______ ______ _____________________________________________ -1 1 2 3 4 5 6 7 mild moderate severe _______________________________________________________ normal severely hypernasal

Nasal emission

• Considered articulation, not resonance • But related to VPI; often co-exists with hypernasality • Audible or inaudible (“visible”) nasal escape during production of speech, esp. pressure consonants

Phoneme-specific nasal emission

• Learned articulatory error (pattern) • Not due to physical cause (i.e. adequate VP closure). Sometimes history VPI, HI • Normal resonance (no hypernasality) • NE during production of some but not all pressure consonants (e.g. /s/) • Treatment: traditional articulation • = “phoneme specific VPI” • NE can accompany or replace target pressure consonant • Peterson-Falzone & Graham ( 1990).

Nasal turbulence

• NE + some intranasal resistance to airflow • Severe form of nasal emission? (Peterson-Falzone et al, 1990) • Smaller VP gap? (Kummer et al., 1992) • Other terms: Nasal snort, nasopharyngeal snort, nasal rustle, posterior nasal fricative – Some debate re: similarities, differences, causes

Low-tech, no-tech evaluation of resonance and nasal emission

• Cul-de-sac test • Modified tongue-anchor technique • Mirror • See-scape • Nasal tube/stethescope

Cul-de-sac test

• Bzoch, 1979. • Also known as: Hypernasality/hyponasality test, Pinch test • Listen for shift in resonance when nares are occluded (“pinced”) vs. unoccluded.

• Bzoch: 10 wds (/b/-initial); can use vowels, other stimuli • If sounds hypernasal when unoccluded, cul-de-sac resonance when occluded => hypernasal • Questionable reliability with some children; procedure can be confusing for users; inappropriate if hyponasality present

Modified tongue anchor

• Useful for detecting nasal emission • Suggestive of VPI and/or O-N fistula • Puff up cheeks with lip seal – Problem: compensatory tongue action – Solution: tongue protrusion • Disadvantage: can take time to model/learn • Advantage: quite sensitive screening tool for VPI (Dalston et al., 1990)

Mirror

• Tool: Small mirror, dental mirror, nasal mirror • Method: hold under alternative nostrils during production of speech or non-speech tasks • Rationale: fogging on mirror during production of target oral stimuli indicates inappropriate nasal escape suggestive of VPI/fistulae • Advantage: cheap and easy • Disadvantage: some oral airflow during production of vowels may be normal, need to control speech stimuli carefully (sustained /s/) • Note: Using mirror during non-speech tasks can be useful but may not reflect speech performance

See-scape

• Simple commercial device comprising piston (styrofoam “float”) inside clear vertical tube. Probe tip at end of flexible tube can be placed in nostril. Nasal airflow can be seen by rising piston. • Advantages: inexpensive, provides clear visual feedback • Not reliable enough to quantify severity (evaluation) or progress (therapy); can be affected by humidity • Detects air flow, nasal emission (not hypernasality)

Evaluating Articulation

(= phonology) • Articulation tests – can use either standard or specialized tests • Specialized tests: –

Iowa Pressure Articulation Test

(part of

Templin-Darley Tests of Articulation

, 1969) –

Bzoch Error Patterns Diagnostic Articulation Test

(1979) – Loaded with high-pressure consonants (plosives, fricatives, affricates) - vulnerable in cleft population

Good practice

• Good quality audio (visual) recording – permits research, clinical audit, calculation of reliability, EBP • Evaluate across contexts – Single words, sentences, conversational speech, isolated phonemes and CV syllables • Evaluate stimulability • Detailed transcription

Transcription

• Transcription systems – Shriberg & Kent, 1995; IPA; extIPA (1994; 2002) • Need diacritics – e.g. for nasalized, nasal emission, palatalized, lateralized • May need to note visual information (visual distortions e.g. labial dental inversion, Class III malocclusion)

Next steps

• Error analysis – Phonological process, nonlinear, … – Place, manner, voicing – Identify error patterns • Hypothesize likely cause/contributors

Possible contributors to articulation disorder in CWCP

• VPI (VPD) • Oral-nasal (O-N) fistula • Abnormal dentition/occlusion • Hearing impairment • “Mislearning” – Related to history of structural abnormalities – Unrelated to cleft

Possible consequences

• VPI (VPD)  hypernasality, nasal emission, compensatory articulations • Oral-nasal (O-N) fistula  nasal emission, hypernasality, middorsal palatal stop • Abnormal dentition/occlusion  articulatory distortions, oral substitutions • Hearing impairment  hyper/hyponasality, voicing errors, placement errors, …..

• “Mislearning” – Related to history of structural abnormalities  – Unrelated to cleft  “phonological disorders” see above

Common error patterns

• Substitutions and omissions more common than distortions • Pressure consonants more vulnerable than non-pressure consonants • Place errors more common than manner errors (but nasalization) • Especially: posterior placement (“backing”)

Compensatory articulations

• (Morley, 1970; Morris, 1972; Trost, 1981) • Glottal stop • Pharyngeal fricative

Laryngeal fricative, pharyngeal stop, pharyngeal affricate, velar fricative

, posterior nasal fricative, middorsum palatal stop • Develop in compensation for VPI (or for palatal fistulae, malocclusion) – Unconscious attempt to block air escaping through VP port; create pressure valve at/near VP port

compensatory articulations, continued • Can be difficult to detect, transcribe; reliability is poor (Gooch et al., 2001) • Glottal stop can be mistaken for omission (IC) • Some instructional/training materials available (Trost-Cardamone, 1987; McWilliams & Phillips, 1979; Great Ormond Street, UK)

Active vs. passive errors

• Harding & Grunwell, 1998; Hutters & Bronsted, 1987 • Obligatory vs. compensatory • Both have structural origin (esp. VPI) • Passive/obligatory errors: hypernasality, nasalized oral consonants, weak pressure consonants.

Disappear when structure corrected.

• Active/compensatory errors: e.g. glottal stops. Active attempt to compensate for structural deficit.

Persist when structure corrected.

• Compensatory errors – Subdivided into adaptive and maladaptive • Adaptive – Acoustically/perceptually acceptable but produced in abnormal way (“visual distortion”) – e.g. using tongue vs lower lip [p, b, m]

macroglossia

– labiodental inversion [f, v]

midface hypoplasia

(L. Grames) • Maladaptive – Not acoustically/perceptual normal – E.g. glottal stop, pharyngeal fricative

Nasal grimace

• Facial grimace • May accompany high-pressure consonants • ?Unconscious attempt to block nares, prevent nasal air escape • Suggestive of VPI

Oral examination

• Debate: conduct before or after speech assessment (Peterson-Falzone et al., 2001) • Look for: ON-fistula, occlusion, other structural anomalies which are likely contributing to speech dx • Size/shape of palate and depth of pharynx may be of interest/importance • HOWEVER…

Oral examination, continued • Cannot see the VP port during intra-oral examination • Elevation of velum during sustained vowel is unreliable predictor of VP status • Do not use oral examination to make conclusions re VP status

Speech protocols for the evaluation of articulation and resonance

• recommendations for speech testing materials

Sample protocol for assessment of resonance and articulation Peterson-Falzone et al. (2001) p. 220 Task Rationale for inclusion Articulation testing Repeated productions of high-pressure consonants + vowel Repetition of words containing oral consonants adjacent to nasal consonants Production of sentences containing only oral consonants Production of sentences containing nasal consonants Production of sentences containing no high pressure consonants or nasal consonants Conversational speech Stimulability testing Facilitates pattern analyses and comparison to developmental norms Helpful in examining patterns of nasal emission Assists in examining effect of rapidly alternating velopharyngeal movements Patterns of nasal emission can be more easily examined Facilitates identification of assimilative nasality and hyponasality Facilitates identification of hypernasality by eliminating consonants that can be accompanied by audible nasal emission or hyponasality Most representative sampel of performance; can examine (1) general speech intelligibility, (2) influence of context on production of sounds, and (3) consistency of sound production errors Identify sounds that are readily modified with auditory and visual cues; identify strategies that facilitate correct production of target sounds

Riski [http://www.choa.org/default.aspx?id=764] • Testing for hypernasality – Oral consonants, voiced sounds, high and low vowels, early appearing sounds – E.g. “Buy baby a bib” • Testing for hyponasality – Nasal consonants, voice sounds (nasals), early appearing sounds – E.g. “Mama made some lemon jam” • Testing for nasal air emission – Oral consonants, unvoiced sounds, early appearing sounds – E.g. “Papa piped up”

Other recommendations

• Henningsson et al. (2008). Universal Parameters for Reporting Speech Outcomes in Individuals with Cleft Palate,

CPCJ

• UK (GOS.SP.ASS, Sell et al., 1999; CAPS, Harding et al, 1997) • Scandinavia (ScanCleft)

Additional measures

• Intelligibility • Severity • Acceptability • QoL, impact of speech impairment on daily life • Global measure of severity/impact al., , 2008), (Henningsson et Summary outcome measure (Sell, 2005)

The cleft team wants to hear from you!

• Suspect VPI – Following primary closure (before age 6!) – Following surgery for VPI (e.g. pharyngeal flap, sphincter pharyngoplasty) - may need re-repair – Submucuous cleft (previously undiagnosed) – Congenital VPI (no cleft palate) - VP disproportion, dysarthria

The cleft team wants to hear from you!

• Suspect O-N fistula contributing to speech disorder (Henningsson & Isberg, 1987) • Persistent hyponasality and/or sleep apnea following secondary surgery for VPI

Additional investigations

Cleft team Research VP status Nasendoscopy Videofluoroscopy Nasometry Pressure flow/ aerodynamics accelerometry spectrography fMRI Articulation Electropalatography (EPG) Electromagnetic articulography (EMMA) spectrography ultrasound

Nasendoscopy

• = nasopharyngoscopy • flexible fiberoptic scope inserted through the nostril • superior view of VP port at rest and during speech • Permits visualization and evaluation of all VP structures (velum, posterior pharyngeal wall, lateral pharyngeal walls, …).

Facilitates treatment planning.

• “invasive” procedure, but no radiation involved • Standard speech protocols available

Multiview videofluoroscopy

• Dynamic radiographic assessment (X-ray) • affords multiple views (frontal, lateral, basal) to provide “3-D” picture of VP port • Standard speech protocols available: similar to, but shorter than for nasendoscopy • Disadvantage: radiation exposure (minimal) • Advantages: provides information about height of maximum closure (surgical planning) • Some clients tolerate better than nasendoscopy

Nasometer

• Computer-based; two microphones separated by plate • measures the acoustic energy emitted from the nose and the mouth during speech • calculates ‘nasalance’ (range from 0 to 100%) Nasal acoustic energy Nasal + oral acoustic energy x 100 • Standard speech materials: oral passage & nasal sentences. Normative data available (languages, dialects, age/gender) • no absolute cutoff score for abnormal; higher nasalance score indicative of hypernasality, possible VPI

• Nasalance can be affected by nasal emission, hyponasality. Interpret results with caution. • Can be useful pre-post treatment measure; can be used in treatment (select cases) visual biofeedback

Additional points

• Compensatory articulation <=> VPI – Old belief: need to treat VPI before treating articulation errors – Problem: compensatory errors can mask accurate diagnosis of VPI – Current thinking: correct compensatory errors first; re-evaluate VP status before deciding/treating any VP problem

Additional points, continued • Temporary “correction” of structural defects, for evaluation and differential diagnosis • Block O-N fistula (chewing gum, dental material) • Occlude nares (“pinch”, nose clips)

Additional points, continued • Listeners are influenced by other factors when making perceptual judgements – Facial appearance – Resonance-articulation-voice