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ORIGINAL ARTICLE
Year : 2010  |  Volume : 12  |  Issue : 2  |  Page : 49-54

The anatomical and perceptual correlates of speech intelligibility in children with repaired cleft palate.


Phoniatric Unit, Faculty of Medicine ,Ain Shams University Hospitals, Cairo, Egypt

Date of Web Publication2-Jan-2020

Correspondence Address:
Nahla Abdulaziz Rifaie
31 Hasan Ibrahim Hasan street, from Makram Ebeid, Nasr City, Behind MFCO Helwan. Cairo
Egypt
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/1319-8491.274632

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  Abstract 


Speech is considered as one of the primary outcome measures of cleft lip and palate management. Speech intelligibility in case of velopharyngeal incompetence depends on the summation of the perceptual subjective degree of hypernasality, glottal articulation, pharyngeal articulation and audible nasal air emission.
Objectives: The objective was to correlate between variables related to open nasality and speech intelligibility from anatomical and perceptual point of view to detect which factors have an effect more than others on speech intelligibility.
Methods: This study was carried out on 23 children with a mean age of 12.65 year who were suffering from open nasality of speech after repaired cleft palate and did not received any line of speech therapy. Assessment of the patients included both objective and subjective measures
Results: By using the logistic mutli-regression analysis, 15 subjective and objective variables were arranged in a numerical order to determine the most effective variable on speech intelligibility. It was shown that the most sensitive predictors (P < 0.005) for speech intelligibility were pharyngealization of fricatives and nasalance scores of oral sentence, while the degree of both open nasality, and palatal mobility were moderate sensitive predictors of speech intelligibility, however all the other remaining parameters were the least sensitive predictors of speech intelligibility.
Conclusion: The different parameters used to assess the speech in patients with repaired cleft palate were variably affecting the speech intelligibility. Four certain parameters out of our results were recommended to be highlighted as valid measures of speech outcome in children with hypernasality.

Keywords: Cleft palate; Hypernasality; Speech intelligibility


How to cite this article:
Rifaie NA, Saber AS, Kaddah FA. The anatomical and perceptual correlates of speech intelligibility in children with repaired cleft palate. Saudi J Otorhinolaryngol Head Neck Surg 2010;12:49-54

How to cite this URL:
Rifaie NA, Saber AS, Kaddah FA. The anatomical and perceptual correlates of speech intelligibility in children with repaired cleft palate. Saudi J Otorhinolaryngol Head Neck Surg [serial online] 2010 [cited 2022 Nov 30];12:49-54. Available from: https://www.sjohns.org/text.asp?2010/12/2/49/274632




  Introduction Top


Speech is considered as one of the primary outcome measures of cleft lip and palate management [1]. Speech intelligibility can be defined as what is understood by the listeners of the phonetic realization of speech. In fact, it is the product of a series of interactive processes [2]. This is why the speech rehabilitation in cleft palate children is of fundamental importance in the complete treatment strategies for these malformations [3]. Perceptual speech assessment is central to the evaluation of speech outcomes associated with cleft palate and velopharyngeal dysfunction. However, the complexity of this process is perhaps sometimes underestimated [1]. Gerratte et al. described the perceptual speech assessment as being at the core of the speech and language therapy profession and the standard against which instrumental measures are validated [4]. Speech abnormalities associated with cleft palate have been well documented and these include hypernasality, nasal emissions of air and articulation errors [5]. The variable velopharyngeal (VP) function presents an overall perceptual rating of VP function during speech and the variable hypernasality estimate the perceived degree of inappropriate resonatory coupling between the oral and nasal cavities during speech [6]. It was found that speech intelligibility is influenced by many variables other than the speech characteristics being assessed such as phoneme content, stress, accent intonation and rate [1].

Regarding the anatomical factors, a number of authors compared the effect of different types of clefts on overall intelligibility; nasalance and nasality and found no clear relation [7].

Kotby discussed that excessive nasalization of vowel, audible nasal air escape; consonant imprecision and faulty compensatory articulatory mechanisms are the most disturbing to speech intelligibility [8]. Abdel Haleem concluded that the degree of speech intelligibility in case of velopharyngeal incompetence (VPI) depends on the summation of the perceptual subjective degree of hypernasality, glottal articulation, pharyngeal articulation and audible nasal air emission [9].

In evaluation of different surgical techniques and the timing of surgery, speech therapy may use a variety of speech outcome measures including physiological, instrumental and perceptual. Many such studies have included some global measure of speech performance such as speech intelligibility [10] The objective of this study was to correlate between variables related to open nasality and speech intelligibility from anatomical and perceptual point of view to detect which factors have an effect more than the other on speech intelligibility in order to help guide the type and sequence of intervention and monitor its effect for better results.


  Material and methods Top


This study was carried out on 23 children, 11 males and 12 females with a mean age of 12.65 years (range = 8 to 17 years; SD ±3.379).

This group of patients was suffering from open nasality of speech due to repaired cleft palate but all patients have normal language development and normal mentality. They did not receive any line of speech therapy.


  Methods Top


All the patients group were assessed by the protocol of assessment of velopharyngeal incompetence [11] that is applied in the phoniatric unit, Ain Shams university hospitals. This protocol included subjective as well as quasi- objective measures of evaluation and was comprised of three levels of assessment for case of VPI as follows:

  1. .Elementary diagnostic procedures which included:


    1. Patients and parents interview.
    2. Auditory perceptual assessment of speech: For subjective evaluation of speech by clinician. This evaluation included the degree of open nasality, consonant precisions, audible nasal air escape, faulty compensatory articulatory mechanisms (in the form of glottal articulation, pharynealization of fricatives and Facial grimace) and overall speech intelligibility of speech. All the above elements were graded along a five point scale starting with o (normal) to 4 (severely affected).
    3. Visual Assessment of Vocal Tract:


    4. Using simple clinical examination tools to comment on lip (cleft, intact, scars), dentition, bite (normal, open bite, overbite) alveolus, hard palate (cleft, scars, and fistulas) and soft palate (length, mobility). iv. Simple clinical tests to detect both hypernasality and nasal air emissions during speech using Gutzman’s test ( /a-i/ test )[12] and Czermark’s test (cold mirror test).[13].


  2. Clinical Diagnostic Aids


    1. Documentation of APA by using a high fidelity voice and speech recording.
    2. Documentation of visual assessment by naso pharyngeal videofibroscopy to examine the velar movement (symmetric or deviated) and its degree (0-4), lateral pharyngeal wall and its degree (0-4) and closure shape whether coronal, sagittal, circular or others.


  3. Additional Instrumental Measures


  4. Nasometric assessment by using Kay Nasometer model 6200 -2 with soft ware version 1.5 the nasometer calculates the nasalance score which is the ratio of the nasal to the nasal plus oral acoustic energy multiplied by 100. The mean nasalance scores for the nasal and oral sentences were calculated automatically by the nasometer software.



  Results Top


Age and gender distribution:

The data were collected from 23 patients with hypernasality of speech aging from 8 years to 17years old. The sample was distributed into (11 male and 12 female). The test used in this statistical analysis was ANOVA test. [Table 1]
Table 1: Description of the patients group according to age and gender

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Distribution of the patients group according to the auditory perceptual assessment (APA):

There were two patients with slight hypernasality (9%), eight patients with mild hypernasality (34%), ten patients with moderate hypernasality (44%) and three patients with severe hypernasality (13%). Six patients with slight imprecision of consonant (26%), eleven patients with mild imprecision of consonant (48%), five patients with moderate imprecision of consonant (21%) and one patient with severe imprecision of consonant (5%).According to audible nasal emissions of air .Six patients were no audible nasal emissions of air (26%), eleven patients with mild audible nasal emission of air (48%), six patients with moderate audible nasal emission of air (26%). It was found also those six patients with no pharyngealization of fricative (26%) and seventeen patients with pharynglization of fricative (74%), four patients with no glottal articulation (17%) &nineteen patients with glottal articulation (83%).

Distribution of the patients group according to clinical assessment:

There were nine patients with adequate palatal length (53%), fourteen patients with inadequate palatal length (47%). It was found also that seven patients had poor palatal mobility (30%), ten patients had fair palatal mobility (44%) and six patients had good palatal mobility (26%). According to lateral pharyngeal wall mobility. There were three patients with poor lateral pharyngeal wall mobility (12%), ten patients with fair lateral pharyngeal wall mobility (44%) and ten patients with good lateral pharyngeal wall mobility (44%).

Factors affecting speech intelligibility in patients with repaired cleft palate:

[Table 2] shows the logistic mutli-regression analysis of the variables (Subjective and Objective) in order to detect the most effective variable on speech intelligibility.
Table 2: The logistic mutli-regression analysis of the subjective and objective variables

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Degree means degree of affection of the parameters on speech intelligibility with degree “1” represented the most effective, while degree “15” represented the least effective. F value of the variables of this table was 1.62 which is low. [Table 2].

The sensitive predictors for speech intelligibility in patients with repaired cleft palate:

[Table 3] shows the logistic step wise multi-regression analysis, and showed that the degree of open nasality, pharynglization of fricative, degree of palatal mobility and nasalance scores of oral sentence are the most sensitive predictors for speech intelligibility. F value (13.31) was better than that of variables in [Table 2] reflecting more sensitivity of these variables in [Table 3]. [Table 4] showes the logistic stepwise multi-regression analysis and reveals that both pharyngealization of fricatives and nasalance score of oral sentence were the most sensitive predictors for speech intelligibility. F value (13.994) was the most sensitive one of all variables.
Table 3: Logistic step wise multi-regression analysis of the most sensitive predictors for speech intelligibility.

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Table 4: The logistic step wise multiregression analysis of the most sensitive predictor for speech intelligibility

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These results showes that the most sensitive predictors (P <.005) for speech intelligibility were pharyngealiza- tion of fricatives and nasalance scores of oral sentence. While open nasality and palatal mobility were moderate sensitive predictors of speech intelligibility. However, all the other remaining parameters were the least sensitive predictors of speech intelligibility. [Table 4]


  Discussion Top


While surgical approach can rebuild oropharyngeal walls and disfigurement for children born with cleft lip and palate, most children are left with speech and language problems,[14],[15] and subsequent outcome of speech disorders, which in fact could affect the intelligibility but also social competence and emotional development of cleft palate child [3]. Therefore, these individuals require regular speech evaluations starting in the first year of life and often continuing into adulthood [16]. In order for speech to be recognized as an outcome of cleft palate patients management, it has to be easily measured. One of the measurements done in assessing speech is the perceptual assessment of nasality[17]. Perceptual evaluation remains the gold standard for evaluating speech [18]. Speech intelligibility is considered as a general judgment of speech that refers to how well a listener understands it [7]. It is a general recommendation that all studies related to cleft palate speech should include evaluation of speech intelligibility using intelligibility measures that are reliable and valid [10]. Some studies have examined the relationship between perceptual characteristics of speech and the anatomical and physiological characteristics of velopha- ryngeal mechanism[19].

In the present study we used logistic multiple regression analysis in assessing the effect of several subjective and objective variables on speech intelligibility. These included: open nasality, audible nasal emissions of air, imprecision of consonants, glottal articulation, pharyn-gealization of fricatives, palatal length and mobility and nasalance scores of oral and nasal sentences. It was found that open nasality was considered to be one of the most effective factors affecting the speech intelligibility, as hypernasality being mostly altering the vowel production leading to subsequent nasalization of vowels. This is in agreement with Moore, and Sommers [20], who rated intelligibility and hypernasality on seven point equal appearing interval scales for 21consonants and 6 vowels in 16 children with repaired cleft palate. Moore, and Sommers reported that intelligibility decreased across vowels from low to high vowels [20]. They added that the vowel height was considered more important to intelligibility than vowel position and that the correlation between intelligibility and nasality was found to be highly specific [20]. Also, other previous studies [21],[22] showed the strong positive correlation between degree of hypernasality and speech intelligibility.

In this study, pharyngealization of fricatives appeared to be the most prominent feature in the speech of the cleft palate patients that affected its intelligibility, while imprecision of consonants was the least influencing feature. This may be explained that the utterance of a fricative usually entails a little longer time than that of plossives and other consonants, as it needs contact of articulators and flow of air through them which is definitely longer in time of production than the case with plossives that would depend on contact and release of articulators. Being long in time of its utterance, would subsequently make it appear to constitute most of the utterance and this gives it the upper hand in affecting the speech of cleft palate patients more than other consonants. In addition to, the fact that pharyngealization of fricatives is an abnormal substitution of the site of the utterance, which is not the case in imprecision of consonants that comprises only light contact of normally placed articulators. Our Results regarding pharyn-gealization of fricatives agreed with those of McWilliams, [23] who found a negative correlation between consonants articulation and intelligibility. Another study by Subtelny et al. compared the rating of articulation and intelligibility for 52 repaired cleft palate patients. [24] They detected poor correlation between intelligibility and articulation test results, although 34% of subject were considered to have severely defective articulation. [24] Smith and Guyette studied the variable effects of articulation errors on speech intelligibility and reached similar results too. [16] Whereas, Nagarajan et al. mentioned that the effect of articulatory errors on speech intelligibility was variable and that severe articulatory distortions correlated strongly with intelligibility. [25]

In the present study the glottal articulation as one of the perceptual correlates of speech intelligibility of repaired cleft palate patients, was having a moderate influence on the speech intelligibility by the regression analysis, this may be due to that the perception of a glottally articulated sound is most of the time misheard as the original sound, so it does not appear to be affecting the speech intelligibility so much.

As regards the anatomical correlates, this study showed that the palatal mobility was one of the most sensitive predictors of speech intelligibility, and to lesser extent is the palatal length as well as the lateral pharyngeal wall mobility, while velopharyngeal pattern of closure was the least influencing factors. Fletcher26 used multiple regression analysis test and simple correlation analysis in a similar study on 68 children with repaired cleft palate and found that intelligibility could be predicted from ten physiological variables with over 80% accuracy. They mentioned that the three most sensitive variables were velopharyngeal valving, vocal tract constriction and palatal mobility.26 However, Kummer et al. showed that the velar mobility, lateral pharyngeal wall mobility and pattern of velopharyngeal valve closure did not have any influence on speech intelligibility. 19

The need to use nasometery as an effective measurement of perceptual assessment was highlighted by Sweeney and Sell,27 who documented the presence of a week relationship between perceptual rating of hypernasality and nasalance scores for passage containing nasal consonants.

Our study revealed that the nasalance scores of the oral sentence proved to be a more influencing factor than the nasal sentence as regards speech intelligibility. It was even found to be one of the most sensitive predictors of speech intelligibility in cleft palate patients together with the pharyngealization of fricatives. This may be explained by the fact that the nasalance scores are affected more by the oral sentence according to its equation; nasalance % = nasal energy / (nasal + oral energy) %. Whereas the oral sentence is affected by the degree of hypernasility which was a powerful factor influencing the speech intelligibility. Our findings are comparable to the results of Baken and Orlikoff [28].


  Conclusion Top


This study tested the influence of a number of anatomical and perceptual factors on speech intelligibility of repaired cleft palate patients. Of all the factors tested, it was found that four factors (the degree of open nasality, pharyngealization of fricatives, nasalance scores of oral sentence and palatal mobility) were considered to be sensitive predictors for speech intelligibility. Of these four factors, only pharyngealization of fricatives and nasalance scores of oral sentence were the most sensitive as predictors of speech intelligibility. These findings should direct our attention towards starting the speech therapy in these patients by focusing on correcting the pharyngealization problem, followed by other errors, while making the follow up measures by nasometry.



 
  References Top

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    Tables

  [Table 1], [Table 2], [Table 3], [Table 4]



 

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