Ultrasonographic Investigation of Cleft-type Compensatory Articulations

87 Pages·2012·1.31 MB·English

Ultrasonographic Investigation of Cleft-Type
Compensatory Articulations
by
Bojana Radovanovic
A thesis submitted in conformity with the requirements
for the degree of Master of Science
Department of Speech-Language Pathology
University of Toronto
© Copyright by Bojana Radovanovic 2012
Ultrasonographic Investigation of Cleft-Type
Compensatory Articulations
Bojana Radovanovic
Master of Science
Department of Speech-Language Pathology
University of Toronto
2012

Abstract
Cleft lip and/or palate is a craniofacial condition that can lead to complex speech disorders. In
particular, the auditory-perceptual speech assessments of individuals with cleft palate can be
difficult because cleft-type compensatory articulations may be outside of English phonology.
Therefore, it is desirable to supplement auditory-perceptual assessments with instrumental
measurements. In the first study, thirteen participants with cleft-type compensatory articulations
completed ultrasound speech exams. The stimuli were repeated VCV combinations (target
consonants: [], [], [], [], [], []; vowel contexts: [], [], []). Ultrasound imaging confirmed
auditory-perceptual impressions and revealed covert articulatory movements. In the second
study, six participants were assessed after a course of speech therapy. Outcomes were recorded
on a severity metric with categories describing auditory-perceptual and motor aspects of speech
errors. The severity metric quantified the incremental changes in both dimensions. Based on the
research presented, further investigations of cleft palate speech using ultrasound are warranted.
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Acknowledgments

First and foremost, I am indebted to my supervisor, Dr. Tim Bressmann, for his patience,
encouragement, kindness and, of course, knowledge. This thesis would not have been possible
without him.
I am extremely grateful to Dr. Pascal van Lieshout and Dr. Gajanan K. Kulkarni for being such
supportive committee members. Their insightful criticism and guidance throughout this process
were critical. I would also like to acknowledge Dr. Aravind Kumar Namasivayam and Dr. Alexei
Kochetov for their advice as members of my defense committee.
I would like to thank the entire Voice and Resonance Lab team, and in particular Gillian de Boer,
Susan Harper and Christina Khaouli Tannous, for their help, friendship and support.
I am thankful as well to my many amazing friends, for their encouragement during strenuous
times. I am so appreciative of the emotional support they provide in all areas of my life.
My parents, Sasha and Jasmina Radovanovic, have been an unwavering source of support –
emotional, moral and of course financial – during all my years. It is to them that this thesis is
dedicated. And finally, a thank you to Nikola Radovanovic for being everything a little brother
should be.
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Table of Contents
Abstract ........................................................................................................................................... ii

Acknowledgements ........................................................................................................................ iii

List of Tables ................................................................................................................................ vii

List of Figures .............................................................................................................................. viii

List of Appendices .......................................................................................................................... x

1. Introduction ................................................................................................................................. 1

1.1 Cleft Lip and Palate ............................................................................................................... 1
1.1.1 Prevalence ....................................................................................................................... 3
1.1.2 Cleft Lip and Palate Embryology and Etiology ............................................................. 3
1.1.3 Cleft Lip and Palate Repair ............................................................................................ 5

1.2 Consequences of Cleft Lip and Palate ................................................................................... 6
1.2.1 Non-Speech Consequences of a Cleft ............................................................................ 6
1.2.2 Speech Consequences of Cleft Lip and Palate ............................................................... 7
1.2.2.1 The Velopharyngeal Mechanism ............................................................................ 7
1.2.2.2 Velopharyngeal Dysfunction .................................................................................. 8
1.2.2.3 Hypernasality and Compensatory Articulations ..................................................... 9

1.3 The Management of Cleft Lip and Palate Speech Problems ............................................... 10
1.3.1 Assessment ................................................................................................................... 10
1.3.1.1 An Instrumental Measure: EPG ............................................................................ 12
1.3.1.2 An Alternative Instrumental Measure: Ultrasound Imaging ............................... 14
1.3.2 Speech Therapy for Cleft-Type Compensatory Articulations ...................................... 15
1.3.3 Severity of the Speech Disorder ................................................................................... 16

1.4 Study Objectives and Rationale .......................................................................................... 18

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2. Exploring Cleft-Type Compensatory Articulations Using Ultrasound Imaging ...................... 19

2.1 Participants .......................................................................................................................... 19

2.2 Methods ............................................................................................................................... 20
2.2.1 Materials ....................................................................................................................... 20
2.2.2 Data Collection ............................................................................................................. 21
2.2.3 Data Treatment and Analysis ....................................................................................... 22

2.3 Results ................................................................................................................................. 23
2.3.1 Stops ............................................................................................................................. 23
2.3.1.1 Results for the Alveolar Stop [] ........................................................................... 23
2.3.1.2 Results for the Velar Stop [] ............................................................................... 25
2.3.2 Fricatives ...................................................................................................................... 27
2.3.2.1 Results for the Alveolar Fricative [] ................................................................... 27
2.3.2.2 Results for the Postalveolar Fricative [] .............................................................. 29
2.3.3 Nasals ........................................................................................................................... 30
2.3.3.1 Results for the Alveolar Nasal [] ........................................................................ 30
2.3.3.2 Results for the Velar Nasal [] ............................................................................. 32

2.4 Discussion ........................................................................................................................... 33
2.4.1 Stops ............................................................................................................................. 33
2.4.2 Fricatives ...................................................................................................................... 35
2.4.3 Nasals ........................................................................................................................... 37
2.4.4 Clinical Implications .................................................................................................... 38

3. Developing and Evaluating a Scoring Metric for Cleft-Type Compensatory Articulations..... 40

3.1 Participants .......................................................................................................................... 40

3.2 Methods ............................................................................................................................... 40
3.2.1 Materials, Data Collection and Treatment .................................................................... 40
3.2.2 Intervention ................................................................................................................... 41
3.2.3 Scoring Metric .............................................................................................................. 43
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3.2.4 Data Analysis ................................................................................................................ 45

3.3 Results ................................................................................................................................. 45
3.3.1 Stop [] .......................................................................................................................... 46
3.3.2 Stop [] ......................................................................................................................... 48
3.3.3 Fricative [] .................................................................................................................. 50
3.3.4 Average Change ........................................................................................................... 52

3.4 Discussion ........................................................................................................................... 53

4. Limitations ............................................................................................................................... 55

5. Conclusion ................................................................................................................................ 56

7. References ................................................................................................................................. 57

Appendix A ................................................................................................................................... 71

Appendix B ................................................................................................................................... 77

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List of Tables
Table 1. Information about cleft type, age and sex of the participants in Study I.
Table 2. Vowel-consonant-vowel stimuli used.
Table 3. Summary of participant realizations (%) for the alveolar stop target [].
Table 4. Summary of participant realizations (%) for the velar stop target [].
Table 5. Summary of participant realizations (%) for the alveolar fricative target [].
Table 6. Summary of participant realizations (%) for the postalveolar fricative target [].
Table 7. Summary of participant realizations (%) for the alveolar nasal target [].
Table 8. Amount of clicking (%) accompanying the nasal targets [] and [].
Table 9. Summary of participant realizations (%) for the velar nasal target [].
Table 10. Study II participant information.
Table 11. Severity scoring sheet for [t].
Table 12. Severity scoring sheet for [k].
Table 13. Severity scoring sheet for [s].
Table 14. Speech severity of 6 participants before and after biofeedback speech
therapy. The average change per participant and across participants is shown.
Table 15. Auditory-perceptual and visual judgments of realizations produced by 2 participants
before and after biofeedback speech therapy for the alveolar stop [t].
Table 16. Auditory-perceptual and visual judgments of realizations produced by 2 participants
before and after biofeedback speech therapy for the velar stop [k].
Table 17. Auditory-perceptual and visual judgments of realizations produced by 2 participants
before and after biofeedback speech therapy for the alveolar fricative [s].

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List of Figures
Figure 1. Examples of the different severities of cleft lip and palate: (A) an incomplete unilateral
cleft lip; (B) a complete unilateral cleft of the lip and alveolus; (C) A complete bilateral cleft lip
and palate; (D) a complete cleft of the palate only. [www.biomedcentral.com/content/figures/
1471-2350-5-15-1.jpg]
Figure 2. Clefts of the lip: (A) incomplete unilateral cleft lip; (B) complete unilateral cleft lip;
(C) complete bilateral cleft lip. [www.facesofchildren.org/Condition Descriptions]
Figure 3. Clefts of the palate: (A) incomplete cleft palate; (B) complete cleft of the soft and hard
palates. [from: Silva Filho, O.G., Rosa, L.A, & Lauris, R.C.M.C. (2007). Influence of isolated
cleft palate and palatoplasty on the face. Journal of Applied Oral Science, 15, 199-208. Figure 1.
Reprinted with permission.]
Figure 4. The respective contributions of the primary palate (light grey) and the secondary palate
(dark grey) to the completed palate during palatogenesis. [www.motifolio.com/1011244.html]
Figure 5. The velopharyngeal mechanism, when open (A) and closed (B). [modified from
http://quizlet.com/6060746/5070-121-test-3-velopfunction-flash-cards/]
Figure 6. The three basic velopharyngeal closure patterns. The black triangles represent the
magnitude of contribution of each sphincter component to the closure mechanism. [modified
from: Poppelreuter, S., Engelke, W. & Bruns, T. (2000). Quantitative analysis of the
velopharyngeal sphincter function during speech. Cleft-Palate Craniofacial Journal, 37, 157-
165. Figure 4. Reprinted with permission.]
Figure 7. Placement of common cleft-type compensatory plosives: (A) a midpalatal stop; (B) a
pharyngeal stop; (C) a glottal stop. [modified from: Trost, J.E. (1981). Articulatory additions to
the classical description of the speech of persons with cleft palate. Cleft Palate Journal, 18, 193-
203. Figure 4. Reprinted with permission.]
Figure 8. Vocal tract configuration during common cleft-type compensatory articulations. (A)
the posterior nasal fricative: the tongue creates a constriction at the back of the oral cavity while
the velum flutters to produce frication. (B) a double articulation: the articulation here is of an
alveolar and glottal plosive where the air is stopped both at the alveolar ridge and at the glottis.
[modified from: Trost, J.E. (1981). Articulatory additions to the classical description of the
speech of persons with cleft palate. Cleft Palate Journal, 18, 193-203. (Figure 4) Reprinted with
permission.]
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Figure 9. Electropalatography palates from a variety of models: (A) the embedded electrodes;
(B) the wires and connector; and (C) the positioning within a participants mouth. [modified from:
http://rose-medical.com/linguagraph.html, http://achiralblog.learn-alesson.com/2008/02/
electropalatography.html, and http://utlinguistics.blogspot.ca/2010_02_01_archive.html]
Figure 10. Single electropalatography frames from a normal speaker for the fricatives /s/ and //
and the plosives /t/ and /k/.
Figure 11. A single frame of an ultrasound video, with a sagittal tongue view insert to show the
orientation. The curved white line in the ultrasound image represents the tongue surface.
Figure 12. The ultrasound scanner (A) and Comfortable Head Anchor for Sonographic
Examinations (B) used during the assessment protocol.
Figure 13. A frame from the clip of Sabrina’s production of [] showing a 2-point elevation
(arrows) during target realization.
Figure 14. Using ultrasound as biofeedback speech therapy: (A) the image display; (B) setup
during a therapy session.
Figure 15. Radar graph displaying severity scores for Stella before (dark grey) and after (light
grey) biofeedback speech therapy for the alveolar stop [t].
Figure 16. Radar graph displaying severity scores for Sally before (dark grey) and after (light
grey) biofeedback speech therapy for the alveolar stop [t].
Figure 17. Radar graph displaying severity scores for Sandra before (dark grey) and after (light
grey) biofeedback speech therapy for the velar stop [k].
Figure 18. Radar graph displaying severity scores for Sofia before (dark grey) and after (light
grey) biofeedback speech therapy for the velar stop [k].
Figure 19. Radar graph displaying severity scores for Sabrina before (dark grey) and after (light
grey) biofeedback speech therapy for the alveolar fricative [s].
Figure 20. Radar graph displaying severity scores for Steve before (dark grey) and after (light
grey) biofeedback speech therapy for the alveolar fricative [s].
Figure 21. Speech severity of 6 participants before (dark grey) and after (light grey) biofeedback
speech therapy.

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List of Appendices

Appendix A: Severity Scores.
Appendix B: Within-Participant Variation.
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