evaluation of articulation and resonance: age 3 and beyond

1. Evaluation of articulation and resonance: Age 3 and beyond Tara L. Whitehill University of Hong Kong

3. Key Questionswhen 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?

4. Resonance disorder Not a voice disorder Not an articulation disorder Hypernasality Hyponasality Mixed resonance disorder

5. 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

6. 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]).

7. Cul-de-sac resonance Type of hyponasality Anterior nasal obstruction �Muffled� quality

8. Mixed resonance disorder Hypernasality and hyponasality co-exist Not uncommon in cleft palate population Hyponasality can mask hypernasality

9. 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

10. 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

11. 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

12. How to rate resonance? Simple to complex Normal vs. abnormal Hypernasal, hyponasal, mixed Severity (mild, moderate, severe) Consistency

13. 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

14. 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

15. 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).

16. 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

17. Low-tech, no-tech evaluation ofresonance and nasal emission Cul-de-sac test Modified tongue-anchor technique Mirror See-scape Nasal tube/stethescope

18. 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

19. 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)

20. 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

21. 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)

22. 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

23. 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

24. 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)

25. Next steps Error analysis Phonological process, nonlinear, � Place, manner, voicing Identify error patterns Hypothesize likely cause/contributors

26. 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

27. 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 ? see above Unrelated to cleft ?�phonological disorders�

28. 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�)

29. 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

30. 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)

31. 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.

32. 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

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

34. 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�

35. 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

36. Speech protocols for the evaluation of articulation and resonance recommendations for speech testing materials

37. Sample protocol for assessment of resonance and articulationPeterson-Falzone et al. (2001) p. 220

38. 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�

39. 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)

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

41. 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

42. 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

43. Additional investigations

44. 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

46. 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

48. 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

49. 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

50. 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

51. 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)

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