Velopharyngeal closure force and levator veli palatini activation levels in varying phonetic contexts

Differences in velopharyngeal pressures during speech sound production in patients with unilateral cleft lip and palate (UCLP) and healthy individuals

Background

During articulation the velopharynx needs to be opened and closed rapidly and a tight closure is needed. Based on the hypothesis that patients with cleft lip and palate (CLP) produce lower pressures in the velopharynx than healthy individuals, this study compared pressure profiles of the velopharyngeal closure during articulation of different sounds between healthy participants and patients with surgically closed unilateral CLP (UCLP) using high resolution manometry (HRM).

Materials and methods

Ten healthy adult volunteers (group 1: 20-25.5 years) and ten patients with a non-syndromic surgically reconstructed UCLP (group 2: 19.1-26.9 years) were included in this study. Pressure profiles during the articulation of four sounds (/i:/, /s/, /ʃ/ and /n/) were measured by HRM. Maximum, minimum and average pressures, time intervals as well as detection of a previously described 3-phase-model were compared.

Results

Both groups presented with similar pressure curves for each phoneme with regards to the phases described and pressure peaks, but differed in total pressures. An exception was noted for the sound /i:/, where a 3-phase-model could not be seen for most patients with UCLP. Differences in velopharynx pressures of 50% and more were found between the two groups. Maximum and average pressures in the production of the alveolar fricative reached statistical significance.

Conclusions

It can be concluded that velopharyngeal pressures of patients with UCLP are not sufficient to eliminate nasal resonance or turbulence during articulation, especially for more complex sounds. These results support a general understanding of hypernasality during speech implying a (relative) velopharyngeal insufficiency.

Modification of velopharyngeal closure pressures during phonation by neuromuscular electrical stimulation in healthy individuals

Introduction

Rhinophonia aperta may result from velopharyngeal insufficiency. Neuromuscular electrical stimulation (NMES) has been discussed in the context of muscle strengthening. The aim of this study was to evaluate in healthy subjects whether NMES can change the velopharyngeal closure pattern during phonation and increase muscle strength.

Method

Eleven healthy adult volunteers (21-57 years) were included. Pressure profiles were measured by high resolution manometry (HRM): isolated sustained articulation of /a/ over 5 s (protocol 1), isolated NMES applied to soft palate above motor threshold (protocol 2) and combined articulation with NMES (protocol 3). Mean activation pressures (MeanAct), maximum pressures (Max), Area under curve (AUC) and type of velum reactions were compared. A statistical comparison of mean values of protocol 1 versus protocol 3 was carried out using the Wilcoxon signed rank test. Ordinally scaled parameters were analyzed by cross table.

Results

MeanAct values measured: 17.15±20.69 mmHg (protocol 1), 34.59±25.75 mmHg (protocol 3) on average, Max: 37.86±49.17 mmHg (protocol 1), 87.24±59.53 mmHg (protocol 3) and AUC: 17.06±20.70 mmHg.s (protocol 1), 33.76±23.81 mmHg.s (protocol 3). Protocol 2 produced velum reactions on 32 occasions. These presented with MeanAct values of 13.58±12.40 mmHg, Max values of 56.14±53.14 mmHg and AUC values of 13.84±12.78 mmHg.s on average. Statistical analysis comparing protocol 1 and 3 showed more positive ranks for MeanAct, Max and AUC. This difference reached statistical significance (p=0.026) for maximum pressure values.

Conclusions

NMES in combination with articulation results in a change of the velopharyngeal closure pattern with a pressure increase of around 200% in healthy individuals. This might be of therapeutic benefit for patients with velopharyngeal insufficiency.

Simulation of Velopharyngeal Biomechanics Identifies Differences in Sphincter Pharyngoplasty Outcomes: A Matched Case-Control Study

The purpose of this study was to develop a framework for 3D subject-specific computational models capable of simulating velopharyngeal biomechanics for anatomic changes that occur following pharyngoplasty and to gain insight into biomechanical factors that may lead to different speech/surgical outcomes. Patient-specific models for two, matched participants with differing speech/surgical outcomes were developed: one with a successful pharyngoplasty outcome and one with a failed pharyngoplasty outcome. Surgical scenarios were simulated to model pharyngoplasty location, identify LVP muscle biomechanics, and identify an optimal pharyngoplasty location for each participant. These simulations illustrate the potential for optimizing pharyngoplasties based on patient-specific geometry.

Diagnosing and Managing Velopharyngeal Insufficiency in Patients With Cleft Palate After Primary Palatoplasty

Velopharyngeal insufficiency (VPI) after palatoplasty is caused by improper anatomy preventing velopharyngeal closure and manifests as a hypernasal resonance, audible nasal emissions, weak pressure consonants, compensatory articulation, reduced speech loudness, and nostril or facial grimacing. A multidisciplinary team using multimodal instruments (speech analysis, nasoendoscopy, videofluoroscopy, nasometry, and magnetic resonance imaging) to evaluate velopharyngeal function should manage these patients. Careful monitoring of velopharyngeal function by a speech pathologist remains paramount for early identification of VPI and the perceptual assessment should follow a standardized protocol. The greatest methodology problem in CLP studies has been the use of highly variable speech samples making comparison of published results impossible. It is hoped that ongoing international collaborative efforts to standardize procedures for collection and analysis of perceptual data will help this issue. Speech therapy is the mainstay treatment for velopharyngeal mislearning and compensatory articulation, but it cannot improve hypernasality, nasal emissions, or weak pressure consonants, and surgery is the definitive treatment for VPI. Although many surgical methods are available, there is no conclusive data to guide procedure choice. The goal of this review article is to present a review of established diagnostic and management techniques of VPI.

Treatment Outcomes of Interdisciplinary Care on Speech and Health-Related Quality of Life Outcomes in Adults With Cleft Palate

PURPOSE

Individuals born with a cleft palate with or without a cleft lip (CP ± L) often experience functional, aesthetic, and psychosocial consequences well into adulthood. This study aimed to investigate outcomes of speech and health-related quality of life (HRQoL) in adults with a CP ± L who received interdisciplinary cleft care at the Ghent University Hospital using valid, reliable, and condition-specific instruments.

METHOD

Thirteen Belgian Dutch-speaking participants with a CP ± L with a mean age of 25.4 years (SD = 5.1, range: 20-33 years) and an age- and gender-matched control group of 13 participants without a CP ± L with a mean age of 25.2 years (SD = 4.8, range: 20-32 years) were included in this study. Speech characteristics were evaluated perceptually and instrumentally. HRQoL was assessed through standardized patient-reported outcome measures. Outcomes were compared with those of the control group and to normative data where available.

RESULTS

Participants with a CP ± L in this sample demonstrated significantly lower speech acceptability (p < .001) and higher rates of hypernasality (p = .015) and nasal turbulence (p = .005) than the control group. They showed significantly higher satisfaction with appearance of the cleft scar compared with norms of adults with a CP ± L (p = .047). No other differences in speech characteristics, sociodemographics, or HRQoL were found between participants with and without a CP ± L.

CONCLUSIONS

The reduced speech acceptability and the presence of resonance and nasal airflow disorders may indicate the need for standardized long-term outcome measurement and interdisciplinary follow-up for speech characteristics and velopharyngeal insufficiency in young and middle adulthood in future clinical practice. Additional research is necessary to further substantiate these findings and to determine predictors for these continuing complications in adults with a CP ± L.

SUPPLEMENTAL MATERIAL

https://doi.org/10.23641/asha.24243901.

Comparison of velopharyngeal morphology of two palatoplasty techniques in patients with hard and soft cleft palate

Purpose

The study aims to compare the velopharyngeal morphology of hard and soft cleft palate (HSCP) patients after Furlow and Sommerlad palatoplasty.

Patients and methods

A total of 51 patients (20 cases in Furlow palatoplasty group, 16 cases in Sommerlad palatoplasty group and 15 normal children in the control group) were included in our study. Velopharyngeal function and speech outcomes of patients with HSCP who had either Furlow palatoplasty or Sommerlad palatoplasty for cleft palate repair were evaluated by perceptual speech assessment (PSA), lateral cephalometric radiographs and nasopharyngoscopy. To assess velopharyngeal morphology of patients treated with two techqiques, we analyzed measurements such as velar length, pharyngeal depth, and the Adequate ratio (the ratio of velar length to pharyngeal depth). Furthermore, skeletal landmarks including cranial base, cervical vertebrae, posterior nasal spine which were defined as the pharyngeal triangle were measured. Finally, the position of the point U relative to the pharyngeal triangle were compared.

Results

Velopharyngeal closure (VPC) rate in Furlow palatoplasty group accounted for 90%, while that in Sommerlad palatoplasty group was 81.3%. PSA of the former group was significantly better than that of the latter group (P < 0.05). Velar length, pharyngeal depth and the Adequate ratio (1.37 ± 0.14 vs. 1.41 ± 0.15) were comparable between the Furlow group and control group (P > 0.05), while Sommerlad group had a shorter velar length, deeper pharyngeal depth and a smaller Adequate ratio (1.20 ± 0.18) compared to the above two groups (P < 0.05). Furhermore, the point U of Sommerlad group in the pharyngeal triangle was higher than that of the other two groups.

Conclusions

In the treatment modality of patients with HSCP, both Furlow palatoplasty and Sommerlad palatoplasty seem to be effective. Furlow palatoplasty appears to have velopharyngeal morphology similar to normal control group., while Sommerlad group shows a shorter velar length, deeper pharyngeal depth and a smaller Adequate ratio.

Comprehensive evaluation of velopharyngeal function in myasthenia gravis patients

PURPOSE

Hypernasality, which is a symptom of dysarthria, may be seen in patients with Myasthenia Gravis with bulbar symptoms. However, there is not enough evidence to show that these patients may have velopharyngeal dysfunction. This study investigates the features of velopharyngeal function in myasthenia gravis patients using objective and subjective measurement tools.

METHODS

Ten adult myasthenia gravis patients with bulbar symptoms and ten adult myasthenia gravis patients without bulbar symptoms were recruited for this study. Ten healthy subjects were also included as the control group. The nasalance scores of the participants were determined using a nasometer. The degree and pattern of velopharyngeal closure were scored using flexible nasoendoscopy during speech, blowing, dry swallowing, and food swallowing. Perceptual hypernasality was assessed.

RESULTS

Velopharyngeal dysfunction was detected in 50% of the myasthenia gravis patients with bulbar symptoms. Velopharyngeal dysfunction was not seen in myasthenia gravis patients without bulbar symptoms. The degree of velopharyngeal closure in patients with bulbar symptoms differed depending on the tasks being performed. No significant difference in velopharyngeal closure patterns was observed between the groups (p < 0.05).

CONCLUSION

Myasthenia gravis patients with bulbar involvement may have velopharyngeal dysfunction. It is important to conduct a comprehensive evaluation to assess all aspects of the velopharyngeal function.

Reliability of Outcome Measures to Assess Consonant Proficiency Following Cleft Palate Speech Intervention: The Percentage of Consonants Correct Metric and the Probe Scoring System

Purpose This study compared the inter- and intrarater reliability of the percentage of consonants correct (PCC) metrics and the probe scoring system between an experienced and a less experienced rater and between two experienced raters. In addition, these outcome measures' ability to reflect changes following speech intervention was measured. Method During Phase 1, two raters (Rater 1 with 5 years of experience in cleft-related speech disorders and Rater 2 with limited experience in cleft-related speech disorders) independently assessed 134 speech samples at the word and sentence levels, which were collected on different data points before, during, and following a cleft palate speech intervention. During Phase 2, a third rater (with 8 years of experience) analyzed 34 speech samples. The percentage of consonants correct-revised, the percentage of correct places and manners, and probe scores at the word and sentence levels were measured. Results Poor-to-moderate interreliability between Raters 1 and 2 was found due to differences in error classification. Interrater reliability between Raters 1 and 3 was very good for both the PCC metrics and the probe scores. The interrater reliability for the amount of targets elicited was lower compared to the interrater reliability for the amount of targets correct. The probe scoring system demonstrated a greater ability to detect changes toward the correct production of the target consonant compared to the PCC metrics. Conclusions Having an experience with the assessment of cleft-related speech disorders is a crucial factor to gain reliable results. The interrater reliability for the PCC metrics and the probe scoring system between two experienced raters did not differ, suggesting that both outcome measures can be used in cleft palate speech intervention studies. Despite the ability of the probe scoring system to detect changes, further research should provide insight in the benefits of this system both for research and clinical purposes.

The Reliability of Visual Ratings of Velopharyngeal Physiology for Speech

BACKGROUND

Analyze intrarater and interrater reliability for evaluating endoscopic images of velopharyngeal (VP) physiology.

METHOD

Speakers produced 9 speech stimuli representing 4 stimulus types: sustained phonemes, repetitions of "puh," single words, and short phrases. The 37-speaker participants included 16 patients with VP dysfunction and 21 control participants. Five raters independently rated the video images for degree of VP opening, location of opening, and pattern of closure. Outcome measures included intrarater and interrater measures of reliability and the effects of raters and stimulus type on ratings.

RESULTS

Intrarater reliability was acceptable, and ratings were logically consistent. Fixed effects regression coefficients for the patient and the control groups showed that raters were a significant source of variability for degree of opening and pattern of closing. Stimulus type was not a significant source of variation for any metric for the controls, but stimulus type was a significant determinant for degree of opening for patients. The degree of opening was larger for sustained phonemes than for the other speech stimuli. Ratings for degree of opening were most similar for repeated "puh."

CONCLUSIONS

Interrater reliability needs to be improved so that the assessment procedure produces more consistent findings among clinicians, thus strengthening our evidence base for this procedure. Interrater additional research is needed to understand how the stimulus affects ratings of VP physiology, to identify stimuli that yield the most useful clinical information, and to understand how training affects the ratings of VP physiology.

Robust Estimation of Hypernasality in Dysarthria with Acoustic Model Likelihood Features

Hypernasality is a common characteristic symptom across many motor-speech disorders. For voiced sounds, hypernasality introduces an additional resonance in the lower frequencies and, for unvoiced sounds, there is reduced articulatory precision due to air escaping through the nasal cavity. However, the acoustic manifestation of these symptoms is highly variable, making hypernasality estimation very challenging, both for human specialists and automated systems. Previous work in this area relies on either engineered features based on statistical signal processing or machine learning models trained on clinical ratings. Engineered features often fail to capture the complex acoustic patterns associated with hypernasality, whereas metrics based on machine learning are prone to overfitting to the small disease-specific speech datasets on which they are trained. Here we propose a new set of acoustic features that capture these complementary dimensions. The features are based on two acoustic models trained on a large corpus of healthy speech. The first acoustic model aims to measure nasal resonance from voiced sounds, whereas the second acoustic model aims to measure articulatory imprecision from unvoiced sounds. To demonstrate that the features derived from these acoustic models are specific to hypernasal speech, we evaluate them across different dysarthria corpora. Our results show that the features generalize even when training on hypernasal speech from one disease and evaluating on hypernasal speech from another disease (e.g., training on Parkinson's disease, evaluation on Huntington's disease), and when training on neurologically disordered speech but evaluating on cleft palate speech.

Immediate effects of voice focus adjustments on hypernasal speakers' nasalance scores

OBJECTIVES

To explore the immediate effects of voice focus adjustments on the oral-nasal balance of hypernasal speakers, measured with nasalance scores.

METHODS

Five hypernasal speakers (2 M, 3 F) aged 5-12 (SD 2.7) learned to speak with extreme forward and backward voice focus. Speakers repeated oral, nasal, and phonetically balanced stimuli. Nasalance scores were collected with the Nasometer 6450.

RESULTS

From the average baseline of 34.27% for the oral stimulus, nasalance increased to 46.07% in forward and decreased to 30.2% in backward focus. From the average baseline of 64.53% for the nasal stimulus, nasalance decreased to 64.13% in forward and decreased to 51.73% in backward focus. From the average baseline of 51.33% for the phonetically balanced stimulus, nasalance increased to 58.87% in forward and decreased to 46.2% in backward focus.

CONCLUSIONS

Forward voice focus resulted in higher and backward voice focus resulted in lower nasalance scores during speech for a group of hypernasal speakers. However, there was an exception: One male speaker showed decreased nasalance in forward voice focus. Future research should investigate the longer-term effectiveness of the intervention.

Identifying Predictors of Levator Veli Palatini Muscle Contraction During Speech Using Dynamic Magnetic Resonance Imaging

Purpose The purpose of this study was to identify predictors of levator veli palatini (LVP) muscle shortening and maximum contraction velocity in adults with normal anatomy. Method Twenty-two Caucasian English-speaking adults with normal speech and resonance were recruited. Participants included 11 men and 11 women (M = 22.8 years, SD = 4.1) with normal anatomy. Static magnetic resonance images were obtained using a three-dimensional static imaging protocol. Midsagittal and oblique coronal planes were established for visualization of the velum and LVP muscle at rest. Dynamic magnetic resonance images were obtained in the oblique coronal plane during production of "ansa." Amira 6.0.1 Visualization and Volume Modeling Software and MATLAB were used to analyze images and calculate LVP shortening and maximum contraction velocity. Results Significant predictors (p < .05) of maximum LVP shortening during velopharyngeal closure included mean extravelar length, LVP origin-to-origin distance, velar thickness, pharyngeal depth, and velopharyngeal ratio. Significant predictors (p < .05) of maximum contraction velocity during velopharyngeal closure included mean extravelar length, intravelar length, LVP origin-to-origin distance, and velar thickness. Conclusions This study identified six velopharyngeal variables that predict LVP muscle function during real-time speech. These predictors should be considered among children and individuals with repaired cleft palate in future studies.

Analysis of oral-nasal balance after intensive speech therapy combined with speech bulb in speakers with cleft palate and hypernasality

OBJECTIVE

To evaluate the efficacy of the combination of a speech bulb with an intensive speech therapy program in hypernasal participants with cleft palate.

METHODS

Twenty hypernasal speakers with cleft palate (12 females and 8 males, median age 28.45 years), who were wearing speech bulbs underwent an intensive speech therapy program of 45 sessions over 3 weeks. Three experienced speech-language pathologists rated the participants' speech recordings before and after intensive speech therapy, with and without the speech bulb. Nasometric recordings and long-term averaged spectra were also analyzed using repeated-measures ANOVAs.

RESULTS

The ANOVA of the hypernasality ratings showed significant effects of therapy [F (1,19) = 15.97; p < .001], speech bulb [F(1,190 = 28.54, p < .001] and a therapy -speech bulb interaction effect [F(1.19) = 22.30, p < 0.001]. The most favorable listener ratings of hypernasality were obtained post-therapy when participants were wearing their speech bulbs. Without the speech bulb, intensive speech therapy by itself did not result in a significant improvement. With speech bulb, nasalance scores for high [F (1,19) = 14.07, p < .001] and low pressure [F (1,19) = 14.84, p < .001] sentences were significantly lower post-therapy, providing preliminary evidence that an intensive speech therapy program may enhance the effect of a speech bulb. Before and after comparisons of individual nasalance profiles demonstrated variable improvement in 15 participants, no progress in 2 participants and more severe hypernasality after therapy in 3 participants. Long-term averaged spectra corroborated the findings of the perceptual analysis. Based on a frequency bin from 201 to 300 Hz, there was a significant within-subject effect for with and without speech bulb [F(1, 18) = 4.54, p = .047] as well as for before vs. after session [F (1,18) = 7.14, p = .015].

CONCLUSION

The speech bulb in combination with intensive speech therapy resulted in improved oral-nasal balance for the majority of participants. More research is needed to investigate long-term outcomes as well as individual factors contributing to therapy success.

Passavant's ridge during speech production with and without pharyngeal bulb

The objective of this study was to investigate the occurrence of Passavant's ridge in patients with history of cleft palate presenting with velopharyngeal insufficiency (VPI) after primary palatal surgery. Twenty-five adult patients (mean age of 32 years), who wore a pharyngeal bulb prosthesis to correct VPI after primary palatoplasty participated in the study. Presence of Passavant's ridge was investigated in four conditions: prior to pharyngeal bulb for treatment of VPI (C1); during the molding of the pharyngeal bulb (C2); six months after the use of the pharyngeal bulb, but with the prosthesis removed (C3), and six months after the use of the pharyngeal bulb, but with the prosthesis in place (C4). Images of nasoendoscopic assessment of velopharyngeal function were obtained under all conditions were analyzed by speech-pathologists to identify the occurrence of Passavant's ridge during speech production. The results revealed a significant difference between molding condition (C2: 40%) and six months of bulb use (C4: 68%) (p = 0.028). The pharyngeal bulb may elicit the Passavant`s ridge in patients with history of cleft palate presenting with VPI.

Stages in the Development and Validation of a Belgian Dutch Outcome Tool for the Perceptual Evaluation of Speech in Patients With Cleft Palate

Objective:

To develop and validate a Belgian Dutch outcome tool for the perceptual evaluation of speech in patients with cleft palate.

Setting:

Cleft palate team in a tertiary university hospital.

Methods:

The tool was based on the Cleft Audit Protocol for Speech–Augmented (John et al., 2006; Sell et al., 2009), with adaptations to some of the speech variables and the structured listening protocol. Following a preliminary listening experiment in phase 1, the tool was optimized. In the second phase, a listening experiment with 4 experienced listeners was set up to assess face validity, inter- and intrarater reliability and criterion validity.

Results:

Results of phase 1 indicated good to very good inter- and intrarater reliability for the majority of the speech variables, good discriminant validity, and varying sensitivity and specificity based on a comparison with nasalance values and the Nasality Severity Index 2.0 (criterion validity). Results of phase 2 showed good to very good interrater reliability for 5 of the 14 variables and good intrarater reliability in 3 of the 4 experienced listeners. Sensitivity and specificity were sufficient, except the specificity of the hypernasality judgments in comparison with the nasalance values of the oral text. Overall, listeners positively judged the face validity of the tool.

Conclusion:

The 2-phase evaluation indicated varying validity and reliability results. Future studies will aim to optimize validity and reliability of the developed tool based on adaptations to the listening protocol, the addition of speech variables, and the inclusion of a more elaborate training.

Multi-scale modeling of an upper respiratory airway: Effect of mucosal adhesion on Eustachian tube function in young children

BACKGROUND

The Eustachian tube is a collapsible upper respiratory airway that is periodically opened to maintain a healthy middle ear. Young children, <10 years old, exhibit reduced Eustachian tube opening efficiency and are at risk for developing middle ear infections. Although these infections increase mucosal adhesion, it is not known how adhesion forces alters the biomechanics of Eustachian tube opening in young children. This study uses computational techniques to investigate how increased mucosal adhesion alters Eustachian tube function in young children.

METHODS

Multi-scale finite element models were used to simulate the muscle-assisted opening of the Eustachian tube in healthy adults and young children. Airflow during opening was quantified as a function of adhesion strength, muscle forces and tissue mechanics.

FINDINGS

Although Eustachian tube function was sensitive to increased mucosal adhesion in both adults and children, young children developed Eustachian tube dysfunction at significantly lower values of mucosal adhesion. Specifically, the critical adhesion value was 2 orders of magnitude lower in young children as compared to healthy adults. Although increased adhesion did not alter the sensitivity of Eustachian tube function to tensor and levator veli palatini muscles forces, increased adhesion in young children did reduced the sensitivity of Eustachian tube function to changes in cartilage and mucosal tissue stiffness.

INTERPRETATIONS

These results indicate that increased mucosal adhesion can significantly alter the biomechanical mechanisms of Eustachian tube function in young children and that clinical assessment of adhesion levels may be important in therapy selection.

Intravelar and Extravelar Portions of Soft Palate Muscles in Velic Constrictions: A Three-Dimensional Modeling Study

Purpose This study predicts and simulates the function and relative contributions of the intravelar and extravelar portions of the levator veli palatini (LVP) and palatoglossus (PG) muscles in velic constrictions. Method A finite element-based model of the 3-dimensional upper airway structures (palate, pharynx, tongue, jaw, maxilla) was implemented, with LVP and PG divided into intravelar and extravelar portions. Simulations were run to investigate the contributions of these muscles in velopharyngeal port (VPP) closure and constriction of the oropharyngeal isthmus (OPI). Results Simulations reveal that the extravelar portion of LVP, though crucial for lifting the palate, is not sufficient to effect VPP closure. Specifically, the characteristic "bulge" appearing in the posterior soft palate during VPP closure ( Pigott, 1969 ; Serrurier & Badin, 2008 ) is found to result from activation of the intravelar portion of LVP. Likewise, the intravelar portion of posterior PG is crucial in bending the "veil" or "traverse" ( Gick, Francis, Klenin, Mizrahi, & Tom, 2013 ) of the velum anteriorly to produce uvular constrictions of the OPI ( Gick et al., 2014 ). Conclusions Simulations support the view that intravelar LVP and PG play significant roles in VPP and OPI constrictions.

Growth Effects on Velopharyngeal Anatomy From Childhood to Adulthood

Purpose The observed sexual dimorphism of velopharyngeal structures among adult populations has not been observed in the young child (4- to 9-year-old) population. The purpose of this study was to examine the age at which sexual dimorphism of velopharyngeal structures become apparent and to examine how growth trends vary between boys and girls. Method Static 3-dimensional magnetic resonance imaging velopharyngeal data were collected among 202 participants ranging from 4 to 21 years of age. Participants were divided into 3 groups based on age, including Group 1: 4-10 years of age, Group 2: 11-17 years of age, and Group 3: 18-21 years of age. Nine velopharyngeal measures were obtained and compared between groups. Results Significant sex effects were evident for levator length ( p = .011), origin to origin ( p = .018), and velopharyngeal ratio ( p = .036) for those in Group 2 (11-17 years of age). Sex effects became increasingly apparent with age, with 7 of 9 variables becoming significantly different between male and female participants in Group 3. Boys, in general, displayed a delayed growth peak in velopharyngeal growth compared to girls. Conclusion Results from this study demonstrate the growth of velopharyngeal anatomy with sexual dimorphism becoming apparent predominantly after 18 years of age. However, velopharyngeal variables displayed variable growth trends with some variables presenting sexual dimorphism at an earlier age compared to other velopharyngeal variables.

Vowel-Specific Intelligibility and Acoustic Patterns in Individuals With Dysarthria Secondary to Amyotrophic Lateral Sclerosis

Purpose The purpose of the study was to investigate vowel-specific intelligibility and acoustic patterns of individuals with different severities of dysarthria secondary to amyotrophic lateral sclerosis (ALS). Method Twenty-three individuals with dysarthria secondary to ALS and 22 typically aging individuals participated as speakers. Participants with ALS were divided into 2 severity groups (severe, mild). For vowel-specific intelligibility data, 135 listeners participated in the study. Vowel-specific intelligibility, intrinsic vowel duration, 1st and 2nd formants (F1 and F2), vowel inherent spectral change (VISC), and absolute VISC were examined. Results A significant interaction between severity group and the vowel-specific intelligibility pattern as well as F1, F2 VISC, and absolute F2 VISC was observed. Specifically, individuals with severe dysarthria showed a significantly less intelligible /ɪ/ than /ɛ/, unlike individuals with mild dysarthria and typically aging individuals. In addition, vowel intelligibility of /ɪ/ showed the strongest association to the severity measures in individuals with ALS. A number of vowel-specific findings are reported in the acoustic variables. Acoustic correlates of vowel-specific intelligibility were identified. Conclusion Vowel-specific intelligibility patterns are different across severity groups; particularly, low intelligibility of /ɪ/ was noted in individuals with severe dysarthria. Individuals with dysarthria maintained the acoustic contrast in duration and F1 VISC among vowels but did not maintain the other spectral contrasts. Reduction of acoustic vowel space was observed primarily due to high F1 in high vowels in individuals with severe dysarthria. Regression findings suggest that the high F1 values of high and mid vowels and F2 reduction of high- and mid-front vowels decreased vowel-specific intelligibility. In addition, vowel duration influenced the vowel intelligibility of vowels that required short intrinsic vowel duration. Lastly, F2 VISC influenced the vowel intelligibility of /ɪ/. Overall, the vowel-specific intelligibility pattern is related to both vowel-specific characteristics and group-specific articulatory control dysfunction.

Speech and Language Issues in the Cleft Palate Population: The State of the Art

Objective

State-of-the-art activity demands a look back, a look around, and, importantly, a look into the new millennium. The area of speech and language has been an integral part of cleft palate care from the very beginning. This article reviews the development and progression of our knowledge base over the last several decades in the areas of speech; language; anatomy and physiology of the velopharynx; assessment of velopharyngeal function; and treatment, both behavioral and physical, for velopharyngeal problems.

Method

The clear focus is on the cleft palate condition. However, much of what is reviewed applies to persons with other craniofacial disorders and with other underlying causes of velopharyngeal impairment. A major challenge in the next several years is to sort through speech disorders that have a clear anatomic underpinning, and thus are more amenable to physical management, versus those that may be treated successfully using behavioral approaches. Speech professionals must do a better job of finding and applying ways of treating individuals with less severe velopharyngeal impairment, thus avoiding the need for physical management in these persons or ignoring the speech problem altogether.

Conclusion

Early and aggressive management for speech and language disorders should be conducted. For most individuals born with cleft conditions, a realistic goal should be normal speech and language usage by the time the child reaches the school-age years.

Speech Outcome following Treatment in Cross-Linguistic Cleft Palate Studies: Methodological Implications

Objective

In cross-linguistic studies of cleft palate speech outcome following treatment, treatment is the independent variable, speech outcome is the dependent variable, and the speakers’ language background is a background variable, like sex, age, and cleft type, which must be eliminated. This article focuses on language as a background variable and how it should be treated. The methodological problems are illustrated through a presentation of two cross-linguistic speech outcome studies.

Conclusion

When speakers of different language background are included in cleft palate studies of speech outcome following treatment, speech outcome data should be based on speech units that are phonetically identical across languages. This affects the make-up of the speech material used in the study. In practice, the requirement of phonetically identical speech units may not be totally met, and detailed information regarding the interaction between the cleft condition and speech sound production is still required to fully understand how the validity of data is affected if this requirement is not met.

Induced Velopharyngeal Fatigue Effects in Speakers with Repaired Palatal Clefts

Objective:

To address whether speakers with cleft palate exhibit velopharyngeal mechanism fatigue and are more susceptible to muscle fatigue than are speakers without cleft palate.

Methods:

Six adults with repaired palatal clefts and mild-moderate hypernasality served as subjects. Velopharyngeal closure force and levator veli palatini muscle activity were recorded. Subjects were asked to repeat /si/ 100 times while an external load consisting of air pressure (0, 5, 15, 25, 35 cm H2O) was applied via a mask to the nasal side of the velopharyngeal mechanism. Fatigue was defined as a reduction in velopharyngeal closure force across the series of /si/ productions, as evidenced by a negatively sloped regression line fit to the closure force data.

Results:

Absolute levels of velopharyngeal closure force were much lower than those observed previously in speakers without palatal clefts. All subjects showed evidence of fatigue. Furthermore, all subjects demonstrated exhaustion, where they were unable to close the velopharyngeal port against the nasal pressure load. This occurred at pressure load levels lower than those successfully completed by speakers without cleft palate.

Conclusions:

In speakers with a repaired palatal cleft, the velopharyngeal closure muscles may not possess the same strength and/or endurance as in normal speakers. Alternatively, muscles may possess adequate strength, but not be positioned optimally within the velopharynx following cleft palate repair or may be forced to move velopharyngeal structures that are stiffer as a result of surgical scarring.

Examining age, sex, and race characteristics of velopharyngeal structures in 4- to 9-year old children using magnetic resonance imaging

Objective

The purpose of this study was to quantify the growth of the various craniofacial and velopharyngeal structures and examine sex and race effects.

Methods

Eight-five healthy children (53 White and 32 Black) with normal velopharyngeal anatomy between 4 and 9 years of age who met the inclusion criteria and successfully completed the MRI scans were included in the study.

Results

Developmental normative mean values for selected craniometric and velopharyngeal variables by race and sex are reported. Cranial variables (face height, nasion to sella, sella to basion, palate height, palate width) and velopharyngeal variables (levator muscle length, angle of origin, sagittal angle, velar length, velar thickness, velar knee to posterior pharyngeal wall, and posterior nasal spine to levator muscle) demonstrated a trend toward a decrease in angle measures and increase in linear measures as age increased (with the exception of PNS to levator muscle). Only hard palate width and levator muscle length showed a significant sex effect. However, two cranial and six velopharyngeal variables showed a significant race effect. The interactions between sex, race, and age were not statistically significant across all variables, with the exception of posterior nasal spine to posterior pharyngeal wall.

Conclusion

Findings established a large age and race-specific normative reference for craniometiric and velopharyngeal variables. Data reveal minimal sexual dimorphism variables used in the present study; however, significant racial effects were observed.

Nasalization Amplitude-Timing Characteristics of Speakers With and Without Cleft Palate

OBJECTIVES

To examine the amplitude-temporal relationships of acoustic nasalization in speakers with a range of nasality and to determine the extent to which each domain independently predicts the speaker's perceived oral-nasal balance.

DESIGN

Rate-controlled speech samples, consisting of /izinizi/, /azanaza/, and /uzunuzu/, were recorded from 18 participants (14 with repaired cleft palate and 4 without cleft palate) using the Nasometer. The mean nasalance of the entire mid-vowel-nasal consonant-vowel (mid-VNV) sequence (amplitude-domain) and the duration of the nasalized segment of the mid-VNV sequence (temporal-domain) were obtained based on nasalance contours.

RESULTS

Strong linear and vowel-dependent relationships were observed between the 2 domains of nasalization (adjusted R² = 71.5%). Both the amplitude- and temporal-domain measures were found to reliably predict the speaker's perceived oral-nasal balance, with better overall model fit and higher classification accuracy rates observed in /izinizi/ and /uzunuzu/ than in /azanaza/. Despite poor specificity, the temporal-domain measure of /azanaza/ was found to have a strong correlation with the participants' Zoo passage nasalance scores (r_s = .897, p < .01), suggesting its potential utility as a severity indicator of perceived nasality.

CONCLUSIONS

With the use of relatively simple speech tasks and measurements representing the amplitude and temporal domains of nasalization, the present study provided practical guidelines for using the Nasometer in assessing patients with oral-nasal resonance imbalance. Findings suggest that both domain measures of nasalization should be examined across different vowel contexts, given that each domain may provide clinically relevant, yet different, information.

Contributions of the Musculus Uvulae to Velopharyngeal Closure Quantified With a 3-Dimensional Multimuscle Computational Model

The convexity of the dorsal surface of the velum is critical for normal velopharyngeal (VP) function and is largely attributed to the levator veli palatini (LVP) and musculus uvulae (MU). Studies have correlated a concave or flat nasal velar surface to symptoms of VP dysfunction including hypernasality and nasal air emission. In the context of surgical repair of cleft palates, the MU has been given relatively little attention in the literature compared with the larger LVP. A greater understanding of the mechanics of the MU will provide insight into understanding the influence of a dysmorphic MU, as seen in cleft palate, as it relates to VP function. The purpose of this study was to quantify the contributions of the MU to VP closure in a computational model. We created a novel 3-dimensional (3D) finite element model of the VP mechanism from magnetic resonance imaging data collected from an individual with healthy noncleft VP anatomy. The model components included the velum, posterior pharyngeal wall (PPW), LVP, and MU. Simulations were based on the muscle and soft tissue mechanical properties from the literature. We found that, similar to previous hypotheses, the MU acts as (i) a space-occupying structure and (ii) a velar extensor. As a space-occupying structure, the MU helps to nearly triple the midline VP contact length. As a velar extensor, the MU acting alone without the LVP decreases the VP distance 62%. Furthermore, activation of the MU decreases the LVP activation required for closure almost 3-fold, from 20% (without MU) to 8% (with MU). Our study suggests that any possible salvaging and anatomical reconstruction of viable MU tissue in a cleft patient may improve VP closure due to its mechanical function. In the absence or dysfunction of MU tissue, implantation of autologous or engineered tissues at the velar midline, as a possible substitute for the MU, may produce a geometric convexity more favorable to VP closure. In the future, more complex models will provide further insight into optimal surgical reconstruction of the VP musculature in normal and cleft palate populations.

Velopharyngeal Status of Stop Consonants and Vowels Produced by Young Children With and Without Repaired Cleft Palate at 12, 14, and 18 Months of Age: A Preliminary Analysis

Purpose

The objective was to determine velopharyngeal (VP) status of stop consonants and vowels produced by young children with repaired cleft palate (CP) and typically developing (TD) children from 12 to 18 months of age.

Method

Nasal ram pressure (NRP) was monitored in 9 children (5 boys, 4 girls) with repaired CP with or without cleft lip and 9 TD children (5 boys, 4 girls) at 12, 14, and 18 months of age. VP status was categorized as open or closed for oral stops and vowels in three contexts-consonant-vowel syllables, vowel-consonant-vowel syllables, and isolated vowels-on the basis of the presence or absence of positive nasal ram pressure.

Results

At 12 months of age, TD children produced 98% of stops and vowels in syllables with VP closure throughout the entire segment compared with 81% of stops and vowels for children with CP (p < .0001). There were no significant group differences at 14 or 18 months of age.

Conclusions

TD children exhibit consistent VP closure for stop consonants and vowels at 12 months of age. Some children with repaired CP do not achieve consistent closure until 14 months of age, approximately 3 to 4 months following palate repair.

Multi-scale finite element modeling of Eustachian tube function: influence of mucosal adhesion

The inability to open the collapsible Eustachian tube (ET) leads to the development of chronic Otitis Media (OM). Although mucosal inflammation during OM leads to increased mucin gene expression and elevated adhesion forces within the ET lumen, it is not known how changes in mucosal adhesion alter the biomechanical mechanisms of ET function. In this study, we developed a novel multi-scale finite element model of ET function in adults that utilizes adhesion spring elements to simulate changes in mucosal adhesion. Models were created for six adult subjects, and dynamic patterns in muscle contraction were used to simulate the wave-like opening of the ET that occurs during swallowing. Results indicate that ET opening is highly sensitive to the level of mucosal adhesion and that exceeding a critical value of adhesion leads to rapid ET dysfunction. Parameter variation studies and sensitivity analysis indicate that increased mucosal adhesion alters the relative importance of several tissue biomechanical properties. For example, increases in mucosal adhesion reduced the sensitivity of ET function to tensor veli palatini muscle forces but did not alter the insensitivity of ET function to levator veli palatini muscle forces. Interestingly, although changes in cartilage stiffness did not significantly influence ET opening under low adhesion conditions, ET opening was highly sensitive to changes in cartilage stiffness under high adhesion conditions. Therefore, our multi-scale computational models indicate that changes in mucosal adhesion as would occur during inflammatory OM alter the biomechanical mechanisms of ET function. Copyright © 2016 John Wiley & Sons, Ltd.

Quantitative Endoscopic Phototransducer Investigation of Normal Velopharyngeal Physiology

PURPOSE

The purpose of this research was to learn the extent to which healthy individuals vary in their ability to achieve velopharyngeal closure for speech.

METHOD

Twenty healthy adult volunteers (10 women, 10 men) were tested using an endoscopic phototransducer system that tracks variations in velopharyngeal closure during speech production. Each speaker produced multiple repetitions of three utterances that differed in phonetic content. The data were amplitude normalized and averaged for each speaker.

RESULTS

Average phototransducer measurements were similar across subjects for utterances containing only oral phonemes. Average percentage of velopharyngeal closure varied considerably among subjects when producing utterances containing both oral and nasal phonemes (54%-95%). Average percentage of velopharyngeal closure levels were significantly lower (p < .05) for utterances that included nasal consonants.

CONCLUSIONS

Phototransducer measurements of velopharyngeal closure for speech are sensitive to nasal phoneme content. The findings suggest that motor programming that accomplishes rapid oral-nasal velopharyngeal valving for speech may differ among healthy subjects. However, such variations in motor programming may not perceptually affect typical speakers. If present in individuals with abnormal velopharyngeal mechanisms, these variations may help explain variations among speakers in speech outcomes after physical and behavioral management.

Comparison of Fundamental Frequency Nasalance between Trained Singers and Nonsingers for Sung Vowels

Objectives:

The purpose of this study was to determine the effect of vocal training on fundamental frequency nasalance measures under selected vowel and frequency conditions.

Methods:

Fundamental frequency nasalance measures were reported for 2 groups of women: 36 trained singers and 36 nonsingers. Each group sang and sustained the vowels (/i/, /æ/, /u/, /a/) for 6 seconds' duration at 3 frequency levels. A 3-second segment from the middle of each vowel was measured to generate fundamental frequency nasalance scores.

Results:

No significant differences were found in the mean fundamental frequency nasalance scores between the trained singers and the nonsingers. The fundamental frequency nasalance scores were significantly higher for front vowels for both groups. Additionally, both groups displayed a pattern of producing significantly higher fundamental frequency nasalance scores at lower fundamental frequencies than at higher fundamental frequencies.

Conclusions:

These findings support the practice of training singers to elevate the velum when singing at high frequencies but not when singing at low ones.

Velopharyngeal Structural and Functional Assessment of Speech in Young Children Using Dynamic Magnetic Resonance Imaging

OBJECTIVE

The purpose of this study was to demonstrate a novel method for examining the velopharyngeal mechanism using static and dynamic magnetic resonance imaging (MRI) at the sentence-level production in young children with normal anatomy. This study examined whether velopharyngeal events occurring in the midsagittal plane are correlated to muscle events occurring along the plane of velopharyngeal closure. Adenoid involvement in velopharyngeal function was also explored.

METHODS

A high-resolution, T2-weighted turbo-spin-echo three-dimensional anatomical scan was used to acquire static velopharyngeal data and a fast-gradient echo fast low angle shot multishot spiral technique (15.8 frames per second) was used to acquire dynamic data on 11 children between 4 and 9 years old.

RESULTS

Changes in velar knee height from rest to the bilabial /p/ production was strongly correlated with changes in the velar configuration (r = 0.680, P = .021) and levator muscle contraction (r = 0.703, P = .016). Velar configuration was highly correlated to levator muscle changes (r = 0.685, P = .020). Mean alpha angle during bilabial /p/ production was 176°, which demonstrated that subjects achieve velopharyngeal closure at or just below the palatal plane. Subjects with a larger adenoid pad used significantly less (r = -0.660, P = .027) levator muscle contraction compared with individuals with smaller adenoids.

CONCLUSIONS

This study demonstrates a potentially useful technique in dynamic MRI that does not rely on cyclic repetitions or sustained phonation. This study lends support to the clinical potential of dynamic MRI methods for cleft palate management.

Dialectal and gender differences in nasalance for a Mandarin population

The purpose of this study was to determine whether there are dialectal and gender related differences in nasalance of main Mandarin vowels and three sentences in 400 Chinese normal adults. The mean nasalance score difference for dialect and gender was significant (p < .001) in all speech materials. For different dialects, the average nasalance scores show that Chongqing > Beijing > Shanghai > Guangzhou for the nasal sentence, oro-nasal sentence, /a/, /i/ and /u/. In addition, the average nasalance scores of females were higher than those of males for all speech materials in all dialects. The clinical significance of this study can be helpful in making nasalance clinical decisions for Chinese people with cleft palate, hearing disorders and dysarthria with resonance disorders. It also shows the theoretical and socio-cultural features for linguists considering dialects and gender.

A computational model of velopharyngeal closure for simulating cleft palate repair

The levator veli palatini (LVP) muscle has long been recognized as the muscle that contributes most to velopharyngeal (VP) closure and is therefore of principal importance for restoring normal speech in patients with a cleft palate. Different surgical reconstructive procedures can utilize varying degrees of LVP overlap, and this study developed a new finite-element model of VP closure designed to understand the biomechanical effects of LVP overlap. A three-dimensional finite-element model was created from adult anatomical dimensions and parameters taken from the literature. Velopharyngeal function was simulated and compared with experimental measurements of VP closure force from a previous study. Varying degrees of overlap and separation of the LVP were simulated, and the corresponding closure force was calculated. The computational model compares favorably with the experimental measurements of closure force from the literature. Furthermore, the model predicts that there is an optimal level of overlap that maximizes the potential for the LVP to generate closure force. The model predicts that achieving optimal overlap can increase closure force up to roughly 100% when compared with too little or too much overlap. The results of using this new model of VP closure suggest that optimizing LVP overlap may produce improved surgical outcomes due to the intrinsic properties of muscle. Future work will compare these model predictions with clinical observations and provide further insights into optimal cleft palate repair and other craniofacial surgeries.

Speech nasality and nasometry in cleft lip and palate

INTRODUCTION

Perceptual evaluation is considered the gold standard to evaluate speech nasality. Several procedures are used to collect and analyze perceptual data, which makes it susceptible to errors. Therefore, there has been an increasing desire to find methods that can improve the assessment.

OBJECTIVE

To describe and compare the results of speech nasality obtained by assessments of live speech, the Test of Hypernasality (THYPER), assessments of audio recorded speech, and nasometry.

METHODS

A retrospective study consisting of 331 patients with operated unilateral cleft lip and palate. Speech nasality was assessed by four methods of assessment: live perceptual judgement, THYPER, audio-recorded speech sample judgement by multiple judges, and nasometry. All data were collected from medical records of patients, with the exception of the speech sample recording assessment, which was carried out by multiple judges.

RESULTS

The results showed that the highest percentages of absence of hypernasality were obtained from judgements performed live and from the THYPER, with equal results between them (79%). Lower percentages were obtained from the recordings by judges (66%) and from nasometry (57%).

CONCLUSION

The best results among the four speech nasality evaluation methods were obtained for the ones performed live (live nasality judgement by a speech pathologist and THYPER).

A Computational Model Quantifies the Effect of Anatomical Variability on Velopharyngeal Function

PURPOSE

This study predicted the effects of velopharyngeal (VP) anatomical parameters on VP function to provide a greater understanding of speech mechanics and aid in the treatment of speech disorders.

METHOD

We created a computational model of the VP mechanism using dimensions obtained from magnetic resonance imaging measurements of 10 healthy adults. The model components included the levator veli palatini (LVP), the velum, and the posterior pharyngeal wall, and the simulations were based on material parameters from the literature. The outcome metrics were the VP closure force and LVP muscle activation required to achieve VP closure.

RESULTS

Our average model compared favorably with experimental data from the literature. Simulations of 1,000 random anatomies reflected the large variability in closure forces observed experimentally. VP distance had the greatest effect on both outcome metrics when considering the observed anatomic variability. Other anatomical parameters were ranked by their predicted influences on the outcome metrics.

CONCLUSIONS

Our results support the implication that interventions for VP dysfunction that decrease anterior to posterior VP portal distance, increase velar length, and/or increase LVP cross-sectional area may be very effective. Future modeling studies will help to further our understanding of speech mechanics and optimize treatment of speech disorders.

Avaliação da nasalidade de fala na fissura labiopalatina

Objetivo Descrever os resultados da nasalidade de fala de indivíduos com fissura labiopalatina e comparar os achados de nasalidade estabelecidos por meio do julgamento perceptivo-auditivo realizado ao vivo com os achados estabelecidos por análise de gravações por juízes, em dois tipos de amostras de fala. Métodos O estudo envolveu a análise retrospectiva dos resultados de avaliações perceptivo-auditivas da nasalidade de fala realizadas ao vivo por uma fonoaudióloga e o julgamento prospectivo, por consenso de juízas de 100 gravações de amostras de fala, obtidas durante a produção de dois conjuntos de estímulos de fala: um com consoantes de alta pressão (CAP, n=100) e outro com consoantes de baixa pressão (CBP, n=100). Os dados pertenciam a pacientes de ambos os gêneros, com idades entre 5 e 12 anos, que tiveram a fissura labiopalatina operada por um mesmo cirurgião. Resultados A ausência de hipernasalidade foi constatada em 69% dos julgamentos ao vivo. Quando presente, a hipernasalidade leve foi constatada em 23% dos casos, enquanto a hipernasalidade moderada em 8%. Para os julgamentos das amostras gravadas, 50% foram identificadas com hipernasalidade durante a produção das amostras CAP e 62% durante a das amostras CBP. Diferença significativa foi encontrada entre o resultado do julgamento ao vivo e o julgamento pelas juízas nas amostras CAP. A concordância entre as modalidades de avaliação variou de 79% para as amostras CAP e 80% para as amostras CBP, sendo considerada moderada. Conclusão O julgamento perceptivo ao vivo da nasalidade de fala pode detectar melhor a ausência de hipernasalidade, seguida pela hipernasalidade de grau leve, em comparação com o julgamento realizado por juízes múltiplos, a partir de amostras gravadas. Contudo, tem a desvantagem de os dados não poderem ser reproduzidos, nem quantificados, nem compartilhados por outros membros da equipe.

Videofluoroscopic investigation of body position on articulatory positioning

PURPOSE

To quantitatively examine the effects of body position on the positioning of the epiglottis, tongue, and velum at rest and during speech.

METHOD

Videofluoroscopic data were obtained from 12 healthy adults in the supine and upright positions at rest and during speech while the participants produced 12 VCV sequences. The effects of body position, target sounds, and adjacent sounds on structural positioning and vowel formant structure were investigated.

RESULTS

Velar retropositioning in the supine position was the most consistent pattern observed at rest. During speech, all structures, with varying degrees of adjustment, appeared to work against the gravitational pull, resulting in no significant narrowing in the oro- and nasopharyngeal regions while in the supine position. Minimal differences in the formant data between the body positions were also observed. Overall, structural positioning was significantly dependent on the target and adjacent sounds regardless of body position.

CONCLUSIONS

The present study demonstrated that structural positioning in response to gravity varied across individuals based on the type of activities being performed. With varying degrees of positional adjustment across different structures, fairly consistent articulatory positioning in the anterior-posterior dimension was maintained in different body positions during speech.

Comparison of nasal acceleration and nasalance across vowels

PURPOSE

The purpose of this study was to determine the performance of normalized nasal acceleration (NNA) relative to nasalance as estimates of nasalized versus nonnasalized vowel and sentence productions.

METHOD

Participants were 18 healthy speakers of American English. NNA was measured using a custom sensor, and nasalance was measured using the KayPentax Nasometer II. Speech stimuli consisted of CVC syllables with the vowels (//, /æ/, /i/, /u/) and sentences loaded with high front, high back, low front, and low back vowels in both nasal and nonnasal contexts.

RESULTS

NNA showed a small but significant effect of the vowel produced during syllable stimuli but no significant effect of vowel loading during sentence stimuli. Nasalance was significantly affected by the vowel being produced during both syllables and sentences with large effect sizes. Both NNA and nasalance were highly sensitive and specific to nasalization.

CONCLUSIONS

NNA was less affected by vowel than nasalance. Discrimination of nasal versus nonnasal stimuli using NNA and nasalance was comparable, suggesting potential for use of NNA for biofeedback applications. Future work to improve calibration of NNA is needed to lower intersubject variability.

Comparison of videonasoendoscopy and auditory-perceptual evaluation of speech in individuals with cleft lip/palate

Introduction: The velopharyngeal sphincter (VPS) is a muscle belt located between the oropharynx and the nasopharynx. Investigations of velopharyngeal function should include an auditory-perceptual evaluation and at least 1 instrument-based evaluation such as videonasoendoscopy.

Aim: To compare the findings of auditory-perceptual evaluation (hypernasality) and videonasoendoscopy (gap size) in individuals with cleft lip/palate.

Method: This was a retrospective, cross-sectional study assessing 49 subjects, of both sexes, with cleft lip/palate followed up at the Otorhinolaryngology Service and the Speech Therapy outpatient clinic of Hospital de Clínicas de Porto Alegre (HCPA). The results from the auditory-perceptual evaluation and the videonasoendoscopy test were compared with respect to the VPS gap size.

Results: Subjects with moderate/severe hypernasality had more severe velopharyngeal closure impairment than those with a less severe condition. The interaction between hypernasality severity and the presence of other speech disorders (p = 0.035), whether compensatory and/or obligatory, increased the likelihood of having a moderate-to-large gap in the velopharyngeal closure.

Conclusions: We observed an association between the findings of these 2 evaluation methods.

The Impact of Maxillary Osteotomy on Speech Outcomes in Cleft Lip and Palate: An Evidence-Based Approach to Evaluating the Literature

Objective

To undertake a critical and systematic review of the literature on the impact of maxillary advancement on speech outcomes in order to identify current best evidence.

Design and Main Outcome Measures

The following databases were searched: PubMed, CINAHL, and The Cochrane Controlled Trials Register. In addition, reference lists were hand searched for additional articles. Using a predefined framework and set criteria, evidence was evaluated using the assignment of levels of evidence (at least Level III on the evidence hierarchy), calculation of post-hoc power (≥ 0.8), effect size (Cohen's d ≥ 0.5), and adaptation of the parameters as set out by The Cochrane Collaboration.

Results

Of the 40 studies identified, the majority (68%) fell within Level lll.ii, representing cohort-type studies and a fifth (20%) within Level IV, the weakest form of evidence. Power and effect size calculations were only possible in 9 studies for different speech outcomes, and only seven studies met the set criteria for best evidence. Accordingly, current best evidence for articulation exists only for a noncleft population, is conflicting for resonance and nasalance, and is mixed for velopharyngeal function depending on which instrumental measure is used.

Conclusions

There is an obvious need for further prospective research in the field with strong speech methodology such as the undertaking of interrater and intrarater reliability, adequate follow-up, and sufficient sample sizes based on a priori power analyses. Methodologic issues are discussed and recommendations made.

Timing of tensor and levator veli palatini force application determines eustachian tube resistance patterns during the forced-response test

OBJECTIVES

The forced-response test (FRT) is used to assess eustachian tube (ET) function in patients with middle ear disease (otitis media). This test often documents a dynamic pattern of luminal dilation and constriction during swallowing which can be quantified as a function relating active tubal resistance with time. The goal of this study is to use a generalized finite element model (FEM) to test the hypothesis that the relative timing of muscle force application by the tensor veli palatini muscle (mTVP) and levator veli palatini muscle (mLVP) on the ET determines the form of active resistance functions.

METHODS

Seven resistance waveforms were obtained during the FRT in five adult subjects. A 2D FEM of the ET was constructed from an adult histological specimen and viscoelastic tissue mechanical properties were specified based on measurements obtained in each subject. Least-squared regression routines were used to vary the timing and magnitude of mTVP and mLVP force applications to the ET in order to match the active resistance functions recorded during the FRT.

RESULTS

Variation of muscle force timing and magnitude in the FEM simulations reproduced the seven active resistance waveforms with high fidelity. Early application of mTVP force in combination with mLVP force produced a waveform characterized by an initial dilation (low resistances) followed by lumen constriction (higher resistances), while delayed mTVP force application caused an initial lumen constriction followed by dilation.

CONCLUSIONS

These results indicate that the active resistance waveforms observed during the FRT reflect differences in the temporal pattern of mLVP and mTVP force application to the ET and emphasize that, like the mTVP, the mLVP functionally interacts with the ET. Results also indicate that in normal adults contraction of the mLVP promotes lumen constriction and that the initial lumen constriction is highly sensitive to the relative delay timing of mTVP and mLVP force application.

Treatment of persistent post-adenoidectomy velopharyngeal insufficiency by sphincter pharyngoplasty

OBJECTIVE

Persistent hypernasality after adenoidectomy is an infrequent problem in children with normal palate. However if it happened, it can render a child's speech unintelligible resulting in serious affection of social life. We aimed in this study to identify the causes of persistent post-adenoidectomy velopharyngeal insufficiency and to assess the efficacy of sphincter pharyngoplasty in the treatment of such problem.

METHODS

This study was conducted on 18 patients complained of hypernasal speech following removal of their adenoids after variable periods of failed expected spontaneous improvement. Their hypernasality was rated as being mild, moderate and severe, all cases were subjected to conservative treatment in the form of speech therapy for 3 months to correct the problem, and patients that did not respond to speech therapy were subjected to surgical intervention in the form of sphincter pharyngoplasty. Velopharyngeal closure was assessed using flexible nasopharyngoscopy, while speech was assessed using auditory perceptual assessment and nasometry.

RESULTS

Hypernasality was mild in 9 cases, moderate in 7 cases and severe in 2 cases. Flexible nasopharyngoscopy showed occult submucous cleft in 5 cases, short palate in 2 cases, and deep nasopharynx in 3 cases. Speech improvement was achieved in 8 cases after completion of speech therapy program (all had mild hypernasality with no anatomical palatal defects). Ten patients that had palatal defects were subjected to sphincter pharyngoplasty, 8 of them showed complete recovery, while 2 cases with severe hypernasality showed partial improvement of their speech.

CONCLUSIONS

Persistent post-adenoidectomy velopharyngeal insufficiency may be due to anatomical abnormalities of the palate such as an occult submucous cleft, short palate or deep nasopharynx; such conditions may be overlooked during the preoperative preparation for adenoid removal. Speech therapy is an effective method in mild hypernasality especially if there is no anatomical abnormality, while surgical correction is usually needed in moderate and severe cases, and sphincter pharyngoplasty is a useful choice for those patients.

Methodology for speech assessment in the Scandcleft project--an international randomized clinical trial on palatal surgery: experiences from a pilot study

OBJECTIVE

To present the methodology for speech assessment in the Scandcleft project and discuss issues from a pilot study.

DESIGN

Description of methodology and blinded test for speech assessment. Speech samples and instructions for data collection and analysis for comparisons of speech outcomes across five included languages were developed and tested. PARTICIPANTS AND MATERIALS: Randomly selected video recordings of 10 5-year-old children from each language (n = 50) were included in the project. Speech material consisted of test consonants in single words, connected speech, and syllable chains with nasal consonants. Five experienced speech and language pathologists participated as observers.

MAIN OUTCOME MEASURES

Narrow phonetic transcription of test consonants translated into cleft speech characteristics, ordinal scale rating of resonance, and perceived velopharyngeal closure (VPC). A velopharyngeal composite score (VPC-sum) was extrapolated from raw data. Intra-agreement comparisons were performed.

RESULTS

Range for intra-agreement for consonant analysis was 53% to 89%, for hypernasality on high vowels in single words the range was 20% to 80%, and the agreement between the VPC-sum and the overall rating of VPC was 78%.

CONCLUSIONS

Pooling data of speakers of different languages in the same trial and comparing speech outcome across trials seems possible if the assessment of speech concerns consonants and is confined to speech units that are phonetically similar across languages. Agreed conventions and rules are important. A composite variable for perceptual assessment of velopharyngeal function during speech seems usable; whereas, the method for hypernasality evaluation requires further testing.

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.