Tara L. Whitehill

Universal parameters for reporting speech outcomes in individuals with cleft palate

Objective: To achieve consistency and uniformity in reporting speech outcomes in individuals born with cleft palate with or without cleft lip using perceptual parameters that characterize their speech production behavior regardless of the language or languages spoken. Design: A working group of six individuals experienced in speech and cleft palate was formed to develop a system of universal parameters for reporting speech outcomes in individuals born with cleft palate. The system was adopted in conjunction with a workshop held in Washington, D.C., that was devoted to developing the universal system. The system, which was refined further following the workshop, involves a three-stage plan consisting of (1) evaluation, (2) mapping, and (3) reporting. The current report focuses primarily on the third stage, reporting speech outcomes. Results: A set of five universal speech parameters has been devised for the reporting stage. These consist of (1) hypernasality, (2) hyponasality, (3) audible nasal air emission and/or nasal turbulence, (4) consonant production errors, and (5) voice disorder. Also included are speech understandability and speech acceptability, global parameters that can be reported for any type of speech disorder. The parameters are described in detail, and guidelines for speech-sampling content and scoring procedures in relation to the parameters are presented. Conclusion: A plan has been developed to document speech outcomes in individuals with cleft palate, regardless of the spoken language, using a set of five universal reporting parameters and two global speech parameters.

Assessing intelligibility in speakers with cleft palate: a critical review of the literature.

OBJECTIVE A literature review was conducted in order to investigate three research questions: how is speech intelligibility being measured in speakers with cleft lip and palate? Is intelligibility adequately being distinguished from related measures such as acceptability? Has there been an increased understanding of intelligibility deficits in speakers with cleft lip and palate? Fifty-seven relevant articles published between 1960 and 1998 were included in the analysis. RESULTS The results showed an increase in the number of articles that included a measure of intelligibility or a similar measure. Several concerns were raised as a result of the review, including the reliability and validity of measures being employed, adequate definition and differentiation of terms, and the need to determine speech and nonspeech variables contributing to reductions in intelligibility. Relevant literature on intelligibility from fields outside cleft lip and palate is reviewed, and a number of recommendations are made regarding the measurement of intelligibility in speakers with cleft lip and palate.

Nasalance measures in Cantonese-speaking women.

OBJECTIVES To establish and evaluate stimulus materials for nasalance measurement in Cantonese speakers, to provide normative data for Cantonese-speaking women, and to evaluate session-to-session reliability of nasalance measures. PARTICIPANTS AND SETTING One hundred forty-one Cantonese-speaking women with normal resonance who were students in the Department of Speech and Hearing Sciences, University of Hong Kong. PROCEDURES Participants read aloud four speech stimuli: oral sentences, nasal sentences, an oral paragraph (similar to the Zoo Passage), and an oral-nasal paragraph (similar to the Rainbow Passage). Data were collected and analyzed using the Kay Nasometer 6200. Data collection was repeated for a subgroup of speakers (n = 28) on a separate day. Nasalance materials were evaluated by using statistical tests of difference and correlation. RESULTS Group mean (standard deviation) nasalance scores for oral sentences, nasal sentences, oral paragraph, and oral-nasal paragraph were 16.79 (5.99), 55.67 (7.38), 13.68 (7.16), and 35.46 (6.22), respectively. There was a significant difference in mean nasalance scores for oral versus nasal materials. Correlations between stimuli were as expected, ranging from 0.43 to 0.91. Session-to-session reliability was within 5 points for over 95% of speakers for the oral stimuli but for less than 76% of speakers for the nasal and oral-nasal stimuli. CONCLUSIONS Standard nasalance materials have been developed for Cantonese, and normative data have been established for Cantonese women. Evaluation of materials indicated acceptable differentiation between oral and nasal materials. Two stimuli (nasal sentences and oral paragraph) are recommended for future use. Comparison with findings from other languages showed similarities in scores; possible language-specific differences are discussed. Session-to-session reliability was poorer for nasal than oral stimuli.

The Effect of Cranio-Maxillofacial Osteotomies and Distraction Osteogenesis on Speech and Velopharyngeal Status: A Critical Review

Objectives To review the impact of maxillary advancement by orthognathic surgery and distraction osteogenesis on speech and velopharyngeal status based on the literature of the past 30+ years, to review the methods employed in previous studies to explain discrepancies in results, and to make recommendations for future studies. Method Thirty-nine published articles on the effect of cranio-maxillofacial osteotomies and distraction osteogenesis on speech and velopharyngeal status were identified and were systematically analyzed. A total of 747 cases of cleft and noncleft patients were selected, including craniofacial deformities and syndromes mainly involving maxillary hypoplasia. Results Findings varied. Many studies found that surgery had no impact on speech and velopharyngeal status. Some reported worsening only in patients with preexisting velopharyngeal impairment or those with borderline velopharyngeal function before surgery. There was no clear difference in outcome between distraction and conventional osteotomy, although there have been few systematic comparisons. There was great variation among reviewed studies in the number of subjects, speech sample, number and type of listeners, speech outcome measures, and timing of postoperative assessment. Few studies employed reliability measures. Conclusion None of the 39 reviewed studies compared conventional osteotomy and distraction by including both groups in a single study. Randomized controlled trials with adequate number of subjects and follow-up duration are needed.

Speech outcome and velopharyngeal function in cleft palate: comparison of Le Fort I maxillary osteotomy and distraction osteogenesis--early results.

Objective: To compare speech outcome and velopharyngeal (VP) status of subjects with repaired cleft palate who underwent either conventional Le Fort I osteotomy or maxillary distraction osteogenesis to correct maxillary hypoplasia. Design: Prospective randomized study with blind assessment of speech outcome and VP status. Subjects: Twenty-two subjects were randomized into conventional Le Fort I osteotomy and Le Fort I distraction groups. All were native Chinese (Cantonese) speakers. Method: Perceptual judgment of resonance and nasal emission, study of VP structures by nasoendoscopy, and instrumental measurement by nasometry. Assessments were performed preoperatively and at 3 months postoperatively. Main Outcome Measures: Assessment of VP closure, perceptual rating of hypernasality and nasal emission, nasalance, and amount of maxillary advancement. Results: There was no statistical difference in any of the outcome measures between the 10 subjects with conventional Le Fort I osteotomy and the 12 subjects with maxillary distraction: hypernasality (chi-square = 3.850, p = 0.221), nasal emission (chi-square = 0.687, p = 0.774), VP gap size (chi-square = 1.527, p = 0.635, and nasalance (t = −0.145, p = 0.886). There was no correlation between amount of maxillary advancement and any of the outcome measures (p = .05 for all). Changes in VP gap size and resonance are described. Conclusion: Results need to be interpreted with caution because of the small sample size and early follow-up. However, this study utilized an assessment protocol involving a variety of outcome measures and careful consideration of reliability factors, which can be a model for further and follow-up studies.

Effect of intonation on Cantonese lexical tones

In tonal languages, there are potential conflicts between the FO-based changes due to the coexistence of intonation and lexical tones. In the present study, the interaction of tone and intonation in Cantonese was examined using acoustic and perceptual analyses. The acoustic patterns of tones at the initial, medial, and final positions of questions and statements were measured. Results showed that intonation affects both the FO level and contour, while the duration of the six tones varied as a function of positions within intonation contexts. All six tones at the final position of questions showed rising FO contour, regardless of their canonical form. Listeners were overall more accurate in the identification of tones presented within the original carrier than of the same tones in isolation. However, a large proportion of tones 33, 21, 23, and 22 at the final position of questions were misperceived as tone 25 both within the original carrier and as isolated words. These results suggest that although the intonation context provided cues for correct tone identification, the intonation-induced changes in FO contour cannot always be perceptually compensated for, resulting in some erroneous perception of the identity of Cantonese tone.

Nasalance distance and ratio: two new measures.

OBJECTIVES Mean nasalance in speakers with perceptually normal nasal resonance can differ in magnitude considerably. In addition, categorizations of speech based on nasalance scores may not agree with perceptual judgments. To overcome this limitation, we evaluated two new simple measures derived from mean nasalance data: the nasalance distance (range between maximum and minimum nasalance) and the nasalance ratio (minimum nasalance divided by maximum nasalance). SETTING Department of Oral and Maxillofacial Surgery, University of Technology, Munich, Germany. SUBJECTS The sample consisted of 133 cleft lip and palate patients with normal nasal resonance or varying degrees of hypernasality. PROCEDURES Oral and nasal acoustic measurements were made using the NasalView system. Nasalance distance and nasalance ratio were calculated for five non-nasal and three nasal sentences from the modified Heidelberg Rhinophonia Assessment Form. RESULTS Optimum cutoffs were derived from receiver-operating characteristics. Results for the sentence stimuli ranged from 64.4% to 89.6% sensitivity and from 91.2% to 94.1% specificity. When the analysis was limited to only one nonnasal and one nasal sentence, results ranged from 79.7% to 87.5% sensitivity and from 88.2% to 97.1% specificity. CONCLUSIONS We conclude that the two new measurements are valuable in routine clinical examinations. Nasalance distance and ratio derived from sentence stimuli are two useful and easily applicable measures that can be used to supplement the nasalance mean value.

Acoustic correlates of hypernasality

The aim of this study was to apply one‐third‐octave analysis for measuring an acoustic correlate of hypernasality in the speech of adults with a range of aetiologies (dysarthria, maxillectomy and cleft palate). Subjects included 12 speakers with hypernasality and 12 normal controls. The speech material was the vowel /i/ segmented from two Cantonese single words produced by each speaker. The results showed that speakers with hypernasality had significantly higher energy level for the one‐third‐octave bands centred at 630, 800 and 1000 Hz, and significantly lower amplitude for the band centred at 2500 Hz than speakers with normal resonance. These results are in general agreement with past findings about nasalization of vowels. This study showed that one‐third‐octave analysis has high intrajudge reliability and is applicable to the speech of adults with hypernasality due to different etiologies.

Effect of listener training on perceptual judgement of hypernasality

Reliable perceptual judgement is important for documenting the severity of hypernasality, but high reliability can be difficult to obtain. This study investigated the effect of practice and feedback on intra‐judge and inter‐judge reliability of hypernasality judgements. The judges were 36 speech‐language therapy students, who were randomly assigned to three groups for training: (1) Exposure (simple exposure to hypernasal speech samples), (2) Practice‐only (practice with hypernasality judgements without feedback), and (3) Practice‐Feedback (practice with hypernasality judgements with feedback). After training, the judges rated hypernasality in non‐nasal sentences produced by 20 speakers with hypernasality and two normal speakers, using direct magnitude estimation. Both practice groups showed fair‐to‐good inter‐judge reliability for rating the female samples: had more listeners who showed significant intra‐judge reliability, and had significantly larger range of hypernasality ratings than the exposure group. To conclude, practice (with or without feedback) is useful for improving the reliability of hypernasality ratings.

Electropalatography Treatment in an Adult with Late Repair of Cleft Palate

This paper describes the use of electropalatography (EPG) in the treatment of a speech disorder in a Cantonese-speaking woman who had primary repair of the palate at age 13. A multiple-baseline approach was used to document treatment efficacy using electropalatography. The client showed rapid improvement in articulatory placement, with generalization to nontarget phonemes. In addition, improvement was noted in her manner of articulation, with a reduction of nasal emission. The relationship between articulatory placement errors and nasal emission in late repair cleft is discussed. Explanations for the effectiveness of EPG with this client are offered.