JICDRO is a UGC approved journal (Journal no. 63927)

   Table of Contents      
ORIGINAL ARTICLE
Year : 2021  |  Volume : 13  |  Issue : 1  |  Page : 35-41

Correlation of subjective and objective assessment of hypernasality in children with repaired cleft lip and palate


1 Assistant Professor, Department of Speech Language Pathology, JSS Institute of Speech and Hearing, Dharwad, Karnataka, India
2 Director, All India Institute of Speech and Hearing, Mysuru, Karnataka, India

Date of Submission16-Aug-2020
Date of Decision22-Sep-2020
Date of Acceptance21-Oct-2020
Date of Web Publication26-Jun-2021

Correspondence Address:
Mr. K S Girish
JSS Institute of Speech and Hearing, Kelageri, Dharwad - 580 007, Karnataka
India
Login to access the Email id

Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jicdro.jicdro_53_20

Rights and Permissions
   Abstract 


Introduction: Correlational studies between subjective and objective evaluations in the area of cleft lip and palate might provide evidence on the reliability and validity of subjective evaluations. This will, in turn, help in deciding to use subjective evaluations in remote areas. Such correlational studies are scanty in Indian languages. Aims: The present study aimed at correlating the perceptual rating of hypernasality with its instrumental measure in Kannada speaking children with repaired cleft lip and palate (RCLP) across different stimuli. The study also discusses various aspects that affect nasality (the type of speech stimuli and age of first palatal surgery) which helps in better understanding of RCLP cases and their characteristics. Settings and Design: This study was based on correlational research designs. Subjects and Methods: Twenty-three Kannada speaking children with RCLP served as participants. Speech samples (vowels, oral words, nasal words, oral sentences, nasal sentences, and oronasal sentences) of children with RCLP were recorded using a sound level meter and were perceptually evaluated using Henningsson's rating scale by three experienced speech-language pathologists. Furthermore, nasalance values were objectively obtained using a nasometer. Statistical Analysis: This study was statistically analyzed using the Shapiro–Wilk test of normality and Spearman's correlation. Results: The results revealed a high positive correlation (0.78) between the subjective and objective assessment. The different degrees of perceptually rated hypernasality were in a positive correlation with nasometry scores of vowels (0.766), words (0.785), and sentences (0.819). Conclusions: A good correlation was obtained between the subjective and objective measurement of nasality indicating the high utility of perceptual evaluation in remote areas.

Keywords: Age of primary palatal surgery, cleft palate, hypernasality, nasalance values, nasometer, perceptual assessment


How to cite this article:
Girish K S, Pushpavathi M. Correlation of subjective and objective assessment of hypernasality in children with repaired cleft lip and palate. J Int Clin Dent Res Organ 2021;13:35-41

How to cite this URL:
Girish K S, Pushpavathi M. Correlation of subjective and objective assessment of hypernasality in children with repaired cleft lip and palate. J Int Clin Dent Res Organ [serial online] 2021 [cited 2021 Sep 27];13:35-41. Available from: https://www.jicdro.org/text.asp?2021/13/1/35/319527




   Introduction Top


Children with cleft lip and palate (CLP) require early surgical and speech intervention for establishing proper oral motor skills. Early identification and assessment of speech errors are crucial in deciding the type of rehabilitation required. Speech errors in children with CLP include hypernasality, nasal air emission, and articulation errors due to velopharyngeal dysfunction affecting the overall speech intelligibility.

Hypernasality is the abnormal nasal resonance caused due to the coupling of oral and nasal cavities during the production of oral speech sounds.[1] It can be assessed both perceptually and/or instrumentally. Perceptual rating is considered universally as a gold standard method, however fails to assess finer speech variations.[2] Therefore, subjective assessments have to be supplemented by instrumental assessments to measure hypernasality in persons with CLP to ensure the reliability and validity of the results.[1] Currently, the nasometer is the extensively used instrument to measure hypernasality in clinical and research areas.[3] It is a microphone-computer-based system that measures nasalance in percentage by calculating the ratio of the acoustic signal collected at the nasal microphone to the acoustic signal collected at the oral as well as nasal microphone, i.e., nasalance = nasal signal/(oral signal + nasal signal) × 100.[4]

However, nasality varies concerning language, speech stimuli, age, gender, and dialect. Researchers have investigated hypernasality across different languages by correlating perceptual and nasalance values of the nasometer in children with CLP. A good positive correlation was found between perceptual ratings and nasalance values of nasometer in English speaking children (sensitivity – 0.87 and specificity – 0.93;[5] r = 0.74, P < 0.001[6]) and Swedish speaking children (0.47–0.76, P ≤ 0.01).[7] In contrast, low correlation was reported by a few researchers (0.34–0.60, P > 0.05;[8] 0.31–0.37, P > 0.05[9]). Such studies in Indian languages are scanty. Although researchers have found a good correlation between the perceptual and objective measures of nasality in the Kannada language, the test stimuli and the sample size considered were less.[10]

There is a dearth of such studies in the Kannada language. Kannada is a Dravidian language, spoken in the state of Karnataka, India. It has approximately 37 million speakers[11] where the incidence of the orofacial cleft is 0.76/1000 births.[12] As resonance is language-specific, such correlational studies in Kannada speaking children with CLP are important for validating the outcomes of the assessment. Furthermore, fewer studies have correlated subjective and objective evaluations across different stimuli.[9]

The quantifiable data of objective evaluation help in developing normative data. Furthermore, the nasalance data from objective evaluations determine the efficacy of surgical or therapeutic treatment. The present study discusses various aspects that affect nasality, such as type of speech stimuli, age of first palatal surgery which helps in better understanding of repaired CLP (RCLP) cases, and their characteristics. Furthermore, the present study compares the nasalance values of the nasometer for different stimuli across different severities. With this background, the present study aimed at correlating the perceptual rating of hypernasality with its instrumental measure (nasalance value) in Kannada speaking children with RCPL across different stimuli. The objectives included: (1) to perceptually analyze the speech of Kannada speaking children with RCLP, (2) to obtain the nasalance values using nasometer for different stimuli across different severities of perceptually rated hypernasality, and (3) to correlate the perceptual rating of hypernasality with the obtained nasometry values across different stimuli.


   Subjects and Methods Top


Participants

Twenty-three (16 boys and 7 girls) Kannada speaking children with RCLP in the age range of 6–12 years served as participants [Table 1]. Age adequate language abilities were ensured through informal assessment by speech-language pathologist (SLP). Children with associated problems such as hearing loss, intellectual disability, and nasal pathologies were excluded.
Table 1: Details of participants

Click here to view


Procedure and materials

Each child was seated comfortably in a sound-treated room and was asked to repeat the speech stimuli which included three vowels, 15 oral words, five nasal words, five oral sentences, five nasal sentences, and five oronasal sentences (Appendix). All speech samples were recorded in a sound-treated room using Brüel and Kjær Sound Level Meter (Type 2250-s handheld analyzer) kept at a distance of 15 cm from the mouth with an interstimuli gap of about 2 s.

The SLM recoded samples were stored and presented to three experienced SLPs through the headphones (Sennheiser HD 180) in an ambient room for perceptual evaluation. The SLPs had at least 3 years of experience in the field of CLP. They were blindfolded to the objectives as well as to the participants of the study. The oral speech samples were presented randomly to the SLPs and were asked to rate the hypernasality on a four-point rating scale, where “0” represented normal resonance, “1,” “2,” and “3,” represented mild, moderate, and severe hypernasality, respectively.[13] The ratings were made separately for vowels, words, and sentences as per the guidelines given.[13] Furthermore, SLPs were asked to rate the overall degree of hypernasality of each participant. The final rating of overall hypernasality for each participant was based on the consensus among the three judges with 2/3 judges rating as the criteria.

Then, nasometry (Model 6450, Key Elemetrics) was carried out for all the participants in an ambient clinical environment. Nasometer was calibrated before the recording. Each participant was seated comfortably on a chair and the headgear was positioned such that the nasometer separation plate was firmly placed against the upper lip perpendicular to the plane of the nasal septum [Figure 1].
Figure 1: participant seated for the nasometer recording of speech samples

Click here to view


Participants were asked to repeat the stimuli after the tester at a comfortable pitch and loudness. The first trial was considered a practice trial. The responses were recorded and saved in the “.nsp” format for further analysis using the nasometer application. The cursors on the screen were set from onset to the offset of the stimulus for analysis and the mean nasalance values were noted.

Statistical Analysis: The obtained data were subjected to statistical computation using IBM Statistical Package for the Social Sciences software (version 21) (IBM, Bengaluru, Karnataka, India). Shapiro–Wilk test of normality was applied to check the normality, where the test revealed a nonnormal distribution of the data (P < 0.05). Descriptive statistics were done to find the average mean and standard deviation of the nasalance values. Spearman's correlation was carried out to check the correlation between subjective and objective values. Cronbach's alpha was used to check interjudge reliability.

Ethical Clearance

Ethical approval for this study (Reference number for the proposal - WOF-182/2018-19) was provided by the AIISH Ethics Committee (AEC) of All India Institute of Speech and Hearing, Mysuru, Karnataka, India, on 4th May 2020.


   Results Top


Results are reported under three sections. In the first section, the perceptual rating of nasality for participants with RCLP across different stimuli; in the next section, the calculated mean, mean rank, and standard deviation of the nasalance values (objective evaluation) for the same stimuli; and in the last section, the results of correlational analyses of subjective and objective evaluations have been reported.

Results of the perceptual rating of hypernasality

The nasality ratings across vowels, words, and sentences for each participant are tabulated [Table 2]. The SLPs even found normal resonance in some of the children with RLCP for some stimuli. Higher interjudge reliability was found among the three judges (α >0.70).
Table 2: Hypernasality ratings of children with repaired cleft lip and palate across different stimuli

Click here to view


Nasalance values of different stimuli across different severities of perceptually rated hypernasality

The mean nasalance and the standard deviation values of nasometry for different severities of perceptually rated hypernasality across different stimuli were calculated [Table 3].
Table 3: The mean and standard deviation of the nasalance values across different stimuli and severity

Click here to view


Overall mean nasalance values were in the increasing order for normal, mild, moderate, and severe categories. Among oral stimuli, the mean nasalance values of vowels, oral words, oral sentences, and oronasal sentences were in the increasing order for normal, mild, moderate, and severe categories [Table 3]. For the nasal stimuli (nasal words and nasal sentences), the mean nasalance values were highest for the severe category and lowest for the normal category, but the nasalance values for mild and moderate categories were almost similar [Table 3].

Kruskal–Wallis H-test was carried out to check the presence of a significant difference in the nasalance values of all the stimuli across different severities. The mean rank of the nasalance values derived from the Kruskal–Wallis H-test is depicted in [Table 4].
Table 4: Mean rank of the nasalance values across different stimuli and severities

Click here to view


The results showed that there was a statistically significant difference in the nasalance values of oral and oronasal stimuli across different severities, whereas it was not found for nasal stimuli. The mean rank values of all the oral and oronasal stimuli are in the increasing order for normal, mild, moderate, and severe categories but not for nasal stimuli [Table 4].

Correlation of the perceptual rating of hypernasality with the nasometry values across different stimuli

The correlation between the perceptual ratings of hypernasality and the nasalance values was determined across different stimuli by administering Spearman's correlation [Table 5].
Table 5: Correlation between perceptual rating and nasalance values across different stimuli

Click here to view


The results revealed a statistically significant positive correlation between the overall perceptual ratings of different severities of hypernasality and total nasalance values (rs = 0.78, P < 0.05). Even across different stimuli, the results showed a significant positive correlation between the perceptual ratings of hypernasality and total nasalance values in vowel/a/(rs = 0.630, P < 0.05), vowel/i/(rs = 0.811, P < 0.05), vowel/u/(rs = 0.858, P < 0.05), oral words (rs = 0.785, P < 0.05), and oral sentences (rs = 0.819, P < 0.05). The correlation value was highest for vowel/u/, followed by oral sentences, vowel/i/, oral words, and vowel/a/with the lowest value. Considering the stimuli on a whole, oral sentences had the highest correlation and vowels (average of all 3 vowels: rs = 0.766, P < 0.05) had the least correlation.


   Discussion Top


The discussions of the results are explained under the following subsections.

Results of the perceptual rating of hypernasality

The difference in the degree of hypernasality across participants can be attributed to their age at which first palatal surgery was done.[14] Six out of eight children with mild hypernasality had their primary palatal surgery within 1 year 6 months, whereas the other two children had at 4 and 10 years of age (mean age – 2 years 6 months), respectively. Eight out of 12 children with moderate hypernasality had their primary palatal surgery after 1½ years of age, whereas two children had at 1 and 1½ years of age (mean age – 3 years 4 months), respectively. Two out of three children with severe hypernasality had their primary palatal surgery at 9 years of age, whereas the other child had at 1 year 10 months of age (mean age – 6 years 7 months). Spearman's correlation revealed a statistically significant positive correlation between them (rs = 0.483, P = 0.02) indicating that early surgical intervention can reduce the severity of resonance problems in children with CLP. This result agrees with the previous studies indicating a significantly higher prevalence of hypernasality in children with late palatal closure.[14],[15] Other aspects affecting nasality, which include speech therapy, type and extent of the cleft, type of palatal surgery, number of palatal surgeries, maturity, motivation, family support, and socioeconomic status were not considered in the present study.

Nasalance values of different stimuli across different severities of perceptually rated hypernasality

A significant difference in the nasalance values across different severities of nasality for all the stimuli except nasal stimuli (nasal words and nasal sentences) was observed. This result agrees with the Indian study, where the “moderate to severe hypernasality” group had more nasalance values than the “mild hypernasality” group.[10]

Among the entire stimuli, nasalance was more for the vowel/i/, followed by nasal sentences, nasal words, vowel/u/, oronasal sentences, oral sentences, and vowel/a/in children with RCLP. This can be attributed to the pattern of articulation of vowel/i/where the tongue is placed high-front leaving less space in the oral cavity and leading the air to pass through the nasal cavity, whereas during the production of vowel/a/, the tongue is placed low-back leaving more space in the oral cavity for resonating the sound. Furthermore, the words and sentences are combinations of low, mid, and high vowels; therefore, the perceived nasalance was more than the vowel/a/and less than vowel/i/. This agrees with the previous studies who also reported high nasalance scores for vowel/i/, followed by oral sentences and vowel/a/.[10],[16]

Correlation of the perceptual rating of hypernasality with the nasometry values across different stimuli

The results revealed a strong positive correlation between the perceptual ratings of hypernasality and nasometric nasalance values. This suggests that the nasometric findings agree strongly with the perceptual judgments of hypernasality in children with RCLP. This supports the findings of the previous studies who also found a good positive correlation between perceptual ratings and overall nasalance values.[6],[7]

In contrast, researchers have found a low correlation between perceptual evaluation and nasalance values.[8],[9] These contrasts might be due to differences in language (Kannada versus Dutch/Brazilian Portuguese) and the type of stimuli used. The experience and training of the SLPs in perceptually evaluating the speech of CLP is another important factor to be considered,[2] which might have contributed to the low correlation in the previous study. Technical variations of the nasometer can also affect the results suggesting SLPs to vigilantly interpret the nasalance values.

Within the type of stimuli, a statistically significant positive correlation between the perceptual ratings of hypernasality and nasalance values for all was observed except for nasal stimuli. Vowels/u/,/i/, and oral sentences had better correlation than oral words and vowel/a/. On the whole, oral sentences had the highest correlation, and vowels (average of all 3 vowels: rs = 0.766, P < 0.05) had the least. This might be attributed to the fact that children with the history of CLP have inefficiency in coarticulation leading to the abnormal coupling of oral and nasal cavities. This agrees with the results of a previously done study, where they found that listener reliability for rating nasality was higher for sentences than for words and isolated vowels.[17]


   Conclusions Top


The findings of the present study showed a good correlation between subjective and objective evaluation results of hypernasality in children with RCLP indicating perceptual assessment to be the gold standard for evaluating in remote areas. However, objective assessment is essential allowing us to quantify the data and keeping track of the therapeutic progress. Furthermore, it emphasizes the need to have such studies carried out in various languages to provide better assessment and management to clients with RCLP across India.

Clinical implication

The present study correlated subjective evaluation results with the objective evaluation results of hypernasality in Kannada speaking children with RCLP, which is very important for validating the outcomes of the assessment. Resonance is not just language specific, it also varies with respect to the stimuli, so the quantifiable data of objective evaluation help in developing normative data for different severities of hypernasality with respect to the stimuli. Furthermore, the nasalance data from the objective evaluation determine the efficacy of surgical or therapeutic treatment. The present study also discussed various aspects that affect nasality, such as type of speech stimuli, age of first palatal surgery which helps in better understanding of RCLP cases and their characteristics for future investigations.

Acknowledgment

The authors would like to thank “NASOSPEECH: Development of Diagnostic System for Severity Assessment of the Disordered Speech,” funded by the Department of Biotechnology (DBT - No. SH/PL/DBT (AKA)/2016-17), Government of India, for funding this research. We wish to thank Dr. Amulya. P. Rao for proofreading the article. The authors would also like to thank the All India Institute of Speech and Hearing, Mysuru, for providing the infrastructure to carry out the study.

Financial support and sponsorship

The authors would like to thank “NASOSPEECH: Development of Diagnostic System for Severity Assessment of the Disordered Speech,” funded by the Department of Biotechnology (DBT - No. SH/PL/DBT (AKA)/2016-17), Government of India, for funding this research.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
Kummer AW. Cleft Palate & Craniofacial Anomalies: Effects on Speech and Resonance. 3rd ed. New York: Cengage Learning; 2014.  Back to cited text no. 1
    
2.
Lewis KE, Watterson TL, Houghton SM. The influence of listener experience and academic training on ratings of nasality. J Commun Disord 2003;36:49-58.  Back to cited text no. 2
    
3.
Bressmann T. Comparison of nasalance scores obtained with the Nasometer, the Nasal View, and the Oro Nasal System. Cleft Palate Craniofac J 2005;42:423-33.  Back to cited text no. 3
    
4.
Fletcher SG. Diagnosing Speech Disorders from Cleft Palate. New York: Grune & Stratton; 1978:92-157.  Back to cited text no. 4
    
5.
Hardin MA, Van Demark DR, Morris HL, Payne MM. Correspondence between nasalance scores and listener judgments of hypernasality and hyponasality. Cleft Palate Craniofac J 1992;29:346-51.  Back to cited text no. 5
    
6.
Sweeney T, Sell D. Relationship between perceptual ratings of nasality and nasometry in children/adolescents with cleft palate and/or velopharyngeal dysfunction. Int J Lang Commun Disord 2008;43:265-82.  Back to cited text no. 6
    
7.
Brunnegård K, Lohmander A, van Doorn J. Comparison between perceptual assessments of nasality and nasalance scores. Int J Lang Commun Disord 2012;47:556-66.  Back to cited text no. 7
    
8.
Keuning KH, Wieneke GH, van Wijngaarden HA, Dejonckere PH. The correlation between nasalance and a differentiated perceptual rating of speech in Dutch patients with velopharyngeal insufficiency. Cleft Palate Craniofac J 2002;39:277-84.  Back to cited text no. 8
    
9.
Pegoraro-Krook MI, Marino VC, Silva L, Dutka JD. Correlation between nasalance and nasality in children with hypernasality. Revista CEFAC 2014;16:1936-44.  Back to cited text no. 9
    
10.
Navya A, Pushpavathi M. Derived nasalance measures of nasality for sentences in children with repaired cleft lip and palate. Lang India 2014;14:1-11.  Back to cited text no. 10
    
11.
Kaminsky AP, Long R. India today: An Encyclopaedia of Life in the Republic. Vol. 1. Santa Barbara: ABC-CLIO; 2011.  Back to cited text no. 11
    
12.
Kumar Ps P, S Dhull K, G L, Singh N. Incidence and demographic patterns of orofacial clefts in Mysuru, Karnataka, India: A hospital-based study. Int J Clin Pediatr Dent 2018;11:371-4.  Back to cited text no. 12
    
13.
Henningsson G, Kuehn DP, Sell D, Sweeney T, Trost-Cardamone JE, Whitehill TL, et al. Universal parameters for reporting speech outcomes in individuals with cleft palate. Cleft Palate Craniofac J 2008;45:1-7.  Back to cited text no. 13
    
14.
Pushpavathi M, Abraham AK, Prasanna SRM, Girish KS. Impact of timing of palatal repair on resonance, understandability, and acceptability in children with repaired cleft lip and palate. Global J Otolaryngol 2018;16:555928.  Back to cited text no. 14
    
15.
Bruneel L, Luyten A, Bettens K, D'haeseleer E, Dhondt C, Hodges A, et al. Delayed primary palatal closure in resource-poor countries: Speech results in Ugandan older children and young adults with cleft (lip and) palate. J Commun Disord 2017;69:1-4.  Back to cited text no. 15
    
16.
Lewis KE, Watterson T, Quint T. The effect of vowels on nasalance scores. Cleft Palate Craniofac J 2000;37:584-9.  Back to cited text no. 16
    
17.
Counihan DT, Cullinan WL. Reliability and dispersion of nasality ratings. Cleft Palate J 1970;7:261-70.  Back to cited text no. 17
    


    Figures

  [Figure 1]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]



 

Top
 
 
  Search
 
    Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
 Related articles
    Access Statistics
    Email Alert *
    Add to My List *
* Registration required (free)  

 
  In this article
    Abstract
   Introduction
   Subjects and Methods
   Results
   Discussion
   Conclusions
    References
    Article Figures
    Article Tables

 Article Access Statistics
    Viewed370    
    Printed16    
    Emailed0    
    PDF Downloaded55    
    Comments [Add]    

Recommend this journal