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The nature of articulation errors in Egyptian Arabic-speaking children with velopharyngeal insufficiency due to cleft palate
International Journal of Pediatric Otorhinolaryngology 79 (2015) 1527–1532
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The nature of articulation errors in Egyptian Arabic-speaking children with velopharyngeal insufficiency due to cleft palate Tamer Abou-Elsaad a,*, Hemmat Baz a, Omayma Afsah a, Alzahraa Mansy b a b
Phoniatric Units, ORL Departments, Mansoura University Hospitals, Mansoura, Egypt Mansoura General Hospital, Mansoura, Egypt
A R T I C L E I N F O
A B S T R A C T
Article history: Received 26 May 2015 Received in revised form 29 June 2015 Accepted 3 July 2015 Available online 14 July 2015
Even with early surgical repair, the majority of cleft palate children demonstrate articulation errors and have typical cleft palate speech. Objective: Was to determine the nature of articulation errors of Arabic consonants in Egyptian Arabicspeaking children with velopharyngeal insufficiency (VPI). Subjects and methods: Thirty Egyptian Arabic-speaking children with VPI due to cleft palate (whether primary repaired or secondary repaired) were studied. Auditory perceptual assessment (APA) of children speech was conducted. Nasopharyngoscopy was done to assess the velopharyngeal port (VPP) movements while the child was repeating speech tasks. Mansoura Arabic Articulation test (MAAT) was performed to analyze the consonants articulation of these children. Results and conclusion: The most frequent type of articulatory errors observed was substitution, more specifically, backing. Pharyngealization of anterior fricatives was the most frequent substitution, especially for the /s/ sound. The most frequent substituting sounds for other sounds were /// followed by / k/ and /n/ sounds. Significant correlations were found between the degrees of the open nasality and VPP closure and the articulation errors. On the other hand, the sounds (///,/£/,/?/,/n/,/w/,/j/) were normally articulated in all studied group. The determination of articulation errors in VPI children could guide the therapists for designing appropriate speech therapy programs for these cases. ß 2015 Elsevier Ireland Ltd. All rights reserved.
Keywords: Velo-pharyngeal insufficiency Arabic consonants Cleft palate speech Arabic articulation test Child speech disorders Child disability
1. Introduction Velopharyngeal Insufficiency (VPI) means the inability of velum and pharyngeal muscles to produce optimal sphincter-like closure between the oro- and nasopharynx [1]. It may be related to organic or functional etiology but most frequently occurs as a result of cleft palate [2]. Even with early surgical repair, the majority of cleft palate children demonstrate articulation errors and have typical cleft palate speech [3]. Speech characteristics, such as hypernasality, nasal air emission and weak consonants are the direct result of a velopharyngeal or palatal opening. These characteristics have been described as passive speech characteristics [4] or obligatory articulatory errors [5] because they are the product of structural abnormality rather than learned abnormal articulatory behaviors. In contrast, articulatory
* Corresponding author at: Phoniatric Unit, ORL Department, Faculty of Medicine, Mansoura University, Mansoura 35516, Egypt. Tel.: +20 1005192300. E-mail address: [email protected] (T. Abou-Elsaad). http://dx.doi.org/10.1016/j.ijporl.2015.07.003 0165-5876/ß 2015 Elsevier Ireland Ltd. All rights reserved.
errors which occur in response to VPI are considered as active speech characteristics or compensatory articulatory errors. These errors often develop as a response to inadequate intraoral pressure for normal articulation [6]. When the compensatory articulatory errors developed, the manner of production is usually maintained. However, the place of articulation is altered and moved posteriorly to the pharynx or larynx. Examples of these compensatory errors are mid-dorsum palatal stops, velar fricatives, nasal snort, pharyngeal plosives, posterior nasal fricatives and glottal stops [6]. Many of the compensatory sounds do not normally occur in the target language of the child [4,7]. In Arabic, for instance, a glottal stop is a sound of frequent occurrence, while in English; the glottal stop is not normally included within its phonemic inventory. A distinction between obligatory errors and compensatory errors is important to make because the compensatory characteristics are under the patient’s control and can therefore be modified with speech therapy. Obligatory errors are purely the results of abnormal structure and require surgical or prosthetic intervention for correction [6]. Colloquial Egyptian Arabic (CEA) is a dialect of Arabic which consists of 27consonant and eight vowel phonemes with a wide range of places of articulation that span the whole vocal tract from
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lips to glottis [8]. The consonant inventory of CEA includes the primary emphatic phonemes /t/, /d/, /s/, /z/, which causes the Arabic language to be distinguished from the great majority of European languages [9,10]. The Arabic inventory includes back consonants that are either glottal (///), velar (/x/, /g/) or pharyngeal (/9/, /?/) [11]. Kummer [12] believed that the diagnosis of VPI cannot be made until the child begins to produce connected speech and can adequately co-operate with the clinician; which is typically around the age of 3 years. Speech therapy for improvement of articulation placement can be done before the surgery and again after the surgery until errors are corrected [13]. The objective of this study was to determine the nature of articulation errors of Arabic consonants in Egyptian Arabicspeaking children with VPI due to cleft palate in order to highlight the speech problems of these children which would allow for designing appropriate speech therapy programs for them. 2. Subjects and methods Thirty Egyptian Arabic-speaking children with VPI due to cleft palate (whether primary repaired or secondary repaired) were studied. They were 16 females (53.3%) and 14 males (46.7%) with their ages ranged between 3 and 9 years (mean = 5.5 1.61 years) and were uttering at least three-word sentences in order to get reliable speech samples. None of the children received previous speech therapy. Children with sensorineural hearing loss, mental retardation and syndromic cleft palate were excluded from the study. Informed consents were obtained from the parents of the children to participate in the study and the ethical committee of the Mansoura faculty of medicine approved the protocol of the research work. All cases were subjected to history taking, clinical examination, and auditory perceptual assessment (APA) of speech. The latter included reporting on nasality (its type and degree), consonant precision, compensatory articulatory mechanisms (glottal and pharyngeal articulation), facial grimace, audible nasal emission of air and overall intelligibility of speech. All the above elements were graded along a 5-point scale starting with 0 (normal) to 4 (severely affected) [14]. Nasopharyngoscopy was done to assess the velopharyngeal port (VPP) movements while the child was repeating speech tasks including vowels, consonants and automatic speech (counting from 1 to 10) [15]. The pattern of closure of VPP whether coronal, sagittal, circular or circular with passavant’s ridge was specified. Also the degree of closure was determined. The movement of each of the velum, lateral and posterior pharyngeal walls was given a score (0–4) where G0 = the resting (breathing) position, GII = half the distance to the corresponding wall, GIV = the maximum movement reaching and touching the opposite wall [16]. Since the degree of closure was not always consistent in all speech tasks, grading was given as follows: G0, G0–I, GI, GI–II, GII, GII–III, GIII, GIII–IV, and GIV. For examples, if the degree of closure was GI in all speech tasks, the child was given GI. If the degree of closure was GI in vowels but GII in consonants and automatic speech, the child was given GI–II. Psychometric evaluation was done using Stanford Binnet intelligence scale ‘‘4th Arabic version’’[17] for determination of mental age to exclude cases with mental retardation. The Preschool language scale ‘‘4th Arabic Version’’[18] was done for determination of language age. For evaluation of the child’s articulation, Mansoura Arabic Articulation test (MAAT) [19] was performed. After application of MAAT, the consonants were analyzed both individually and after their grouping according to manner and place of articulation into anterior fricatives (including R /s/, /z/, /s/, /z/, / /, /f/), posterior fricatives (including /h/, /?/, /x/, /]/, /£/), anterior plosives (including /b/, /t/, /d/, /d/, /t/), posterior
plosives (including /k/, /g/, and ///), liquids (including /l/, /r/), nasals (including /m/, /n/), and glides (including /j/, /w/). The articulatory errors were labeled as follows: Imprecision. Pharyngealization (when sounds were produced with accompanying constriction of the pharynx). Glottal articulation (when sounds were substituted by /// or /h/). Lateralization (lateral sigmatism). Other substitutions (this term was given for substitution errors other than pharyngealization, glottal articulation and lateralization). Nasal air emission. For calculation of percent errors of sound groups, the percent of children showing the specified error in the individual phonemes constituting the specified group was calculated. Then percent errors of these individual phonemes was summated and divided by the number of these phonemes. For example, calculation of percent errors of anterior fricatives was achieved by summation of percent R of children showing errors in the phonemes /s/, /z/, /s/, /z/, / /, /f/ divided by 6. The results were collected, tabulated, and analyzed using SPSS statistical package Version 15. Qualitative data were presented as numbers and corresponding percentages. The non-parametric Spearman’s rho and parametric Pearson correlation tests were used to measure the relationship between variables. p value was considered statistically significant if <0.05. 3. Results 3.1. Descriptive statistics The results of APA revealed that the majority of the studied children had mild (13 cases) and moderate (10 cases) degrees of open nasality while the rest had slight (5 cases) and severe (2 cases) degrees. One or more of the Arabic consonants were imprecised in 29 cases, nasally air emitted in 26 cases. Pharyngealization of fricatives was observed in 23 cases and glottal articulation in 9 cases. Compensatory facial grimace was observed in 7 cases of the studied children. The overall intelligibility of speech was slightly impaired in 15 cases, mildly impaired in 12 cases and moderately impaired in 3 cases of VPI children (Table 1). Table 1 Description of APA of all studied children (n = 30). Variable
Grade
No of patients
% of patients
Open nasality
G1 G2 G3 G4
5 13 10 2
16.7 43.3 33.3 6.7
Consonant imprecision
G0 (Absent) G1 (Present)
1 29
3.3 96.7
Unintelligibility of speech
G1 G2 G3 G4
15 12 3 0
50.0 40.0 10.0 0
Pharyngealization of fricatives
G0 (Absent) G1 (Present)
7 23
23.3 76.7
Glottal articulation
G0 (Absent) G1 (Present)
21 9
70 30
Nasal air emission
G0 (Absent) G1 (Present)
4 26
13.3 86.7
Facial grimace
G0 (Absent) G1 (Present)
23 7
76.7 23.3
(Slight) (Mild) (Moderate) (Severe)
(Slight) (Mild) (Moderate) (Severe)
T. Abou-Elsaad et al. / International Journal of Pediatric Otorhinolaryngology 79 (2015) 1527–1532 Table 2 Degree of VPP closure of all studied children (n = 30) as revealed by nasoendoscopy.
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Table 3 Pattern of VPP closure of all studied children (n = 30) as revealed by nasoendoscopy.
Degree of VPP closure
Number of patients
% of patients
Pattern of VPP closure
Number of patients
% of patients
G G G G G G G G G
0 0 2 5 5 4 2 12 0
0 0 6.7 16.7 16.7 13.3 6.7 40 0
Coronal Circular Sagittal Circular with Passavant’s ridge
14 10 3 3
46.7 33.3 10.0 10.0
0 0–I I I–II II II–III III III–IV IV
Nasoendoscopic assessments revealed that the majority of children (12 cases, 40%) demonstrated grade III-IV closure of VPP (Table 2). The most frequently observed pattern of VPP closure was coronal pattern (14 cases, 46.7%) and the least observed pattern was sagittal and circular with Passavant’s ridge (3 cases, 10% each) (Table 3). Application of MAAT revealed that substitution was the most frequent type of articulatory errors in all groups of sounds except liquids and glides. The calculated percent of substitutions was 46.12% for anterior plosives, 38.35% for posterior plosives, 68.85% for anterior fricatives, and 12.66% for posterior fricatives. On the other hand, imprecision was the most frequent type of errors observed in the group of liquids, where 23.3% of children demonstrated such error, specifically in /r/ sound. Glides (/j/, / w/) were articulated normally in all studied children. In addition to glides, the consonants (///, /?/, /h/, /n/, /£/) were also normally articulated in all children. A closer look at substitution errors revealed that pharyngealization was the most frequent articulatory error constituting 52.78% of the estimated errors of anterior fricatives (Table 4). The anterior fricatives group was the most frequent group of consonants that were misarticulated (68.85%) and the only group of sounds that showed pharyngealization (Table 4). Predominantly 66.7% of the studied children demonstrated pharyngealization of the /s/ sound (Table 5). The next frequent substitution errors (after pharyngealization of fricatives) observed in the studied children fall under the category ‘‘other substitutions’’. These errors were most frequently observed in /t/ and /d/ sounds (15 cases, 50% each) followed by /d/ (14 cases, 46.7%) and /t/ (13 cases, 43.4%) (Table 5). Considering glottal articulation, the most frequent glottally articulated sounds were the posterior plosives (18.35%) (Table 4). Predominantly /k/ constituted 20% of the glottally articulated sounds (Table 5). Lateralization was only observed in anterior fricatives (8.9%) (Table 4). Predominantly /k/ sounds constituted 16.7% of the lateralized sounds (Table 5). Nasal air emission was most observed in anterior fricatives (56.7%) (Table 4). At the level of individual phonemes (Table 5), /s/ was the most R frequent substituted sound (86.7%), followed by / / (83.3%) then / z/ and /s/ (70.6% each).
Analysis of substitutions among individual phonemes (in relation to each other) revealed that the most frequent substituting sound was /// which substituted for 14 sounds (glottal articulation) (Table 5). Regarding ‘‘other substitutions’’, /k/ and /n/ were the most frequent substituting sounds, especially for anterior sounds. The labial plosive /b/ was most frequently substituted by /m/ (30%) (Table 6). The compensatory articulation errors thus revealed in the study sample include pharyngealization of the anterior fricatives, glottal articulation of both stops and fricatives, and nasal fricatives (the substitution of /f/ by /n/) (Tables 4 and 6). 3.2. Correlative analysis Positive significant correlations were found between the degree of open nasality and the articulatory errors of anterior plosives, posterior plosives, anterior fricatives, posterior fricatives (p < 0.01) and liquids (p < 0.05). On the other hand, non-significant correlation was found between the degree of open nasality and nasals (p > 0.05) (Table 7). Negative significant correlations were found between the degree of nasoendoscopic closure of VPP during automatic speech and the articulation errors of the anterior plosives, posterior plosives, anterior fricatives (p < 0.01). On the other hand, nonsignificant correlations were found between the degree of VPP closure during automatic speech and the articulation errors of the posterior fricatives, nasals and liquids (p > 0.05) (Table 8). No correlations could be statistically conducted with the glides as they were normally articulated in all studied group. 4. Discussion Oral consonants necessitate closed velopharyngeal valve in order to build up the necessary intra-oral pressure for their proper production. Patients with VPI cannot produce this pressure. So these difficulties; with the anatomical defect of cleft patient, constitute the base of the articulatory problems in VPI [20]. The current study was conducted on 30 Egyptian children with VPI following repair of cleft palate, aiming at identifying the nature of their articulation errors for proper decision-making of management. The results of the APA revealed that the majority of studied children had mild and moderate degrees of open nasality.
Table 4 Description of articulatory errors according to place and manner of articulation.
Normal Imprecision Pharyngealization Glottal articulation Lateralization Other substitutions Total substitutions Nasal air emission
Anterior plosives
Posterior plosives
Anterior fricatives
Posterior fricatives
Liquids
Nasals
Glides
36.66% 6.7% 0 9.45% 0 36.67% 46.12% 20%
68.9% 8.3% 0 18.35% 0 20% 38.35% 16.7%
26.7% 4.45% 52.78% 3.3% 8.9% 3.87% 68.85% 56.7%
84% 3.34% 0 4% 0 8.66% 12.66% 0
66.65% 23.3% 0 0 0 21.65% 21.65% 0
98.35% 0 0 0 0 3.3% 3.3% 0
100% 0 0 0 0 0 0 0
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Table 5 Description of articulatory errors in misarticulated sounds in all studied children (n = 30).a Misarticulated sound
Imprecision
/b/ /t/ /g/ /x/ /d/ /r/ /z/ /s/ /R/ /s/ /d/ /t/ /z/ /]/ /f/ /k/ /l/ /m/
0 3 4 3 2 7 2 0 0 0 3 4 2 2 4 1 0 0
a
(10%) (13.3%) (10%) (6.7%) (23.3%) (6.7%)
(10%) (13.3%) (6.7%) (6.7%) (13.3%) (3.3%)
Substitutions
Nasal emission
Pharyngealization
Glottal articulation
Lateralization
Other substitutions
Total substitutions
0 0 0 0 0 0 18 20 17 19 0 0 17 0 4 0 0 0
0 5 5 2 5 0 1 1 1 1 3 4 1 4 1 6 0 0
0 0 0 0 0 0 3 4 5 2 0 0 2 0 0 0 0 0
9 15 10 4 14 10 1 1 2 1 15 13 1 9 1 2 3 1
9 20 15 6 19 10 23 26 25 23 18 17 21 13 6 8 3 1
(60%) (66.7%) (56.7%) (63.3%)
(56.7%) (13.3%)
(16.7%) (16.7%) (6.7%) (16.7%) (3.3%) (3.3%) (3.3%) (3.3%) (10%) (13.3%) (3.3%) (13.3%) (3.3%) (20%)
(10%) (13.3%) (16.7%) (6.7%)
(6.7%)
(30%) (50%) (33.3%) (13.3%) (46.7%) (33.3%) (3.3%) (3.3%) (6.7%) (3.3%) (50%) (43.4%) (3.3%) (30%) (3.3%) (6.7%) (10%) (3.3%)
(30%) (66.7%) (50%) (20%) (63.3%) (33.3%) (70.6%) (86.7%) (83.3%) (70.6%) (60%) (56.7%) (70%) (43.3%) (20%) (20.7%) (10%) (3.3%)
2 2 5 0 0 0 3 3 3 3 1 1 3 0 2 0 0 0
(6.7%) (6.7%) (16.7%)
(10%) (10%) (10%) (10%) (3.3%) (3.3%) (10%) (6.7%)
Values are expressed as number of children showing the error (%).
Nasoendoscopic assessments of these children demonstrated grade III–IV closure of VPP. These results agree with that of Isshiki [21], who found that milder degrees of open nasality coincide with smaller velopharyngeal opening. The most frequent observed pattern of VPP closure was coronal pattern (46.7%). This finding is agreeable with that of Croft et al. [22] who found that coronal pattern was the commonest pattern of closure, representing 55% of their patients.
Table 6 Description of ‘‘other substitutions’’ in all studied children (n = 30). Substituted sound
Substituting sound
Number of children (%)
/b/ /t/
/m/ /k/ /n/ /j/ /k/ /n/ /£/ /k/ /n/ /t/ /g/ /j/ /l/ /n/ /w/ /j/ /£/ /£/ /£/ /s/ /£/ /k/ /g/ /n/ /q/ /t/ /n/ /£/ /x/ /£/ /?/ /n/ /n/ /j/ /n/ /n/
9 13 1 1 9 1 4 6 2 3 1 6 2 4 2 2 1 1 1 1 1 3 3 3 4 2 2 1 7 1 1 1 1 1 3 1
/g/ /x/ /d/
/r/
/z/ /s/ /k/ /S/ /d/
/z/
/f/ /k/ /l/ /m/
(30%) (43.4%) (3.3%) (3.3%) (30%) (3.3%) (13.3%) (20%) (6.7%) (10%) (3.3%) (20%) (6.7%) (13.3%) (6.7%) (6.7%) (3.3%) (3.3%) (3.3%) (3.3%) (3.3%) (10%) (10%) (10%) (13.3%) (6.7%) (6.7%) (3.3%) (23.3%) (3.3%) (3.3%) (3.3%) (3.3%) (3.3%) (10%) (3.3%)
The sounds (///, /£/, /?/, /n/, /w/, /j/) were normally articulated in all studied group since most of those consonants’ constrictions are below the velum. Similar results were obtained by Shahin [23] and Bzoch [24]. On the other hand, we observed the predominance of articulation errors among the anterior fricatives in the current study. This finding is similar to the result of Brandt et al. study [25] who reported that fricatives were the most frequent misarticulated group of sounds in their patients. The current study revealed non-significant correlation between the degree of open nasality and articulatory errors of nasals (p > 0.05). The possible explanation, as stated by Kummer [6], is that nasal sounds occur with open valve and consequently not affected by VPI. On the other hand, articulatory errors of both plosives and anterior fricatives were significantly correlated with the degree of open nasality because these sounds necessitate VPP closure for their production. According to warren [26], the inability to generate and/or maintain adequate levels of intraoral pressure for production of plosion or friction may lead to the development of atypical places of production. This explanation also accounts for the negative significant correlation between the degree of nasoendoscopic closure and articulation errors of plosives and anterior fricatives. Similar to the result of McWilliams [27] study, /s/ sound was the most frequent misarticulated sound by cleft palate patients. Generally, the sibilant fricatives (including /s/) are more distorted than the non-sibilants in these patients because the former have a more strident quality and longer duration than the latter. Also, as
Table 7 Correlation between the degree of open nasality and consonant misarticulation. Consonant misarticulation
Open nasality degree p
r Anterior plosives Posterior plosives Anterior fricatives Posterior fricatives Liquids Nasals Glides
**
0.486 0.644** 0.522** 0.486** 0.407* 0.074 0
0.006 0.000 0.003 0.007 0.026 0.697 0
Non-parametric spearman’s rho correlation and Wilcoxon signed Ranks test. * p < 0.05. ** p < 0.01.
T. Abou-Elsaad et al. / International Journal of Pediatric Otorhinolaryngology 79 (2015) 1527–1532 Table 8 Correlation between the degree of nasoendoscopic closure of VPP during automatic speech and consonant misarticulation. Consonant misarticulation
Closure with automatic speech r
Anterior plosives Posterior plosives Anterior fricatives Posterior fricatives Liquids Nasals Glides
p 0.484** 0.506** 0.476** 0.220 0.346 0.168 0
0.007 0.004 0.008 0.243 0.061 0.376 0
Non-parametric spearman’s rho correlation test and Wilcoxon Signed Ranks test. ** p < 0.01.
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more specifically, backing. Pharyngealization of anterior fricatives was the most frequent substitution, especially for the /s/ sound. The most frequent substituting sounds for other sounds were /// followed by /k/ and /n/ sounds. Significant correlations were found between the degrees of the open nasality and VPP closure and the articulation errors. On the other hand, the sounds (///, /£/, /?/, /n/, / w/, /j/) were normally articulated in all studied group. The determination of articulation errors in VPI children could guide the therapists for designing appropriate speech therapy programs for these cases. Conflicts of interest None.
stated by Fletcher [28], sibilant sounds require precise placement and control of the tongue where it is positioned in contact with the alveolar margins laterally and at a specified distance from the incisor teeth anteriorly. The sibilants also require formation of a medial groove anteriorly between the blade of the tongue and the alveolar ridge. The airstream is then diverted at the VPP from where it flows under pressure through the groove and turbulence space between the tongue and the teeth. The substitution of alveolar sound /t/ by the velar sound /k/ was observed in 43.3% of the studied children. This finding was described by some authors (e.g. Lawrence and Philips [29]; Moller [30] as a common general error pattern in speakers with repaired cleft palate, and was referred to by Gibbon and Crampin [31] as a ‘retracted’ or ‘backed’ tongue. The back tongue position can help to push the velum upward to assist with closure as a compensatory strategy for VPI [32,33], and allows the individual to impound air pressure in the back of the oral cavity. The current study also revealed preponderance of glottal articulation (the glottal stop ///) and the velar stop /k/ as the most common compensatory articulation patterns used by Arabic speaking children with VPI due to cleft palate substituting other consonant sounds. In English, on the other hand, cleft palate children usually use the glottal stop, the pharyngeal stop, the posterior nasal fricative and the velar fricative as posterior placements [34]. Substitutions not only involved the place of articulation, but involved the manner of articulation as well. In the current study, substitution of some oral sounds by nasal sounds (/m/, /n/) was observed in 30%, 20% of the studied children respectively. Such substitutions are considered obligatory errors [6]. This finding could be explained by the abnormal function of the velopharyngeal mechanism where cleft palate speakers compensate for oral sounds by sounds that are easily produced. Thus, attempts to produce voiced plosives may result in the production of their nasal cognates. Even voiceless plosives and other oral sounds can be nasalized due to the open VPP [6]. The labial plosive /b/ was most frequently substituted by /m/ (30%). This error is considered to be due to the fact that /b/ and /m/ are almost identical in articulatory mechanism except for the requirement of velopharyngeal closure during /b/ [21]. The previously mentioned articulation errors in Egyptian Arabic-speaking VPI children should be considered in their speech therapy. The goal of the therapy is to correct placement (and sometimes manner) of production. A further study is needed to examine different approaches for many of articulation errors in Arabic-speaking children with VPI. 5. Conclusion The most frequent type of articulation errors observed in Arabic-speaking VPI children due to cleft palate was substitution,
References [1] J. Hirschberg, Functional consequences of the cleft palate and its management, Orv. Hetil 142 (2001) 1259–1263 (in Hungarian). [2] J. Hirschberg, Velopharyngeal insufficiency, Folia Phoniatr. Logop. 38 (1986) 221–276. [3] C.E. Jones, K.L. Chapman, M.A. Hardin-Jones, Speech development of children with cleft palate before and after palatal surgery, Cleft Palate Craniofac. J. 40 (2003) 19–31. [4] A. Harding, P. Grunwell, Active versus passive cleft-type speech characteristics, Int. J. Lang. Commun. Disord. 33 (1998) 329–352. [5] J.E. Trost-Cardamone, Speech in the first year of life: a perspective on early acquisition, in: D.E. Kernahan, S.W. Rosenstein (Eds.), Cleft Lip Palate: A System of Management, Williams Wilkins, Baltimore, 1990, pp. 91–103. [6] A.W. Kummer, Cleft Palate and Craniofacial Anomalies: Effects on Speech and Resonance, 2nd ed., Thomson Delmar Learning, Clifton Park, NY, 2008. [7] J. Trost, Articulatory additions to the classical descriptions of the speech of persons with cleft palate, Cleft Palate J. 18 (1981) 193–203. [8] R. Harrell, The Phonology of Egyptian Arabic, American Council of Learned Societies, New York, 1957. [9] S. Al-Ani, Arabic Phonology, Mouton, The Hague, 1970. [10] L. Ali, R.G. Daniloff, A contrastive cinefluorographic investigation of the articulation of emphatic-nonemphatic cognate consonants, Stud. Ling. 26 (1972) 81–105. [11] M. Omar, The Acquisition of Egyptian Arabic as a Native Language. Janua Linguarum, Series Practica, vol. 160, 1973, pp. 199–205. [12] A.W. Kummer, Cleft Palate and Craniofacial Anomalies: The Effects on Speech and Resonance, WB Saunders, Cincinnati, OH, 2005, pp. 401–424. [13] J. Hirschberg, Models of management of velopharyngeal valve incompetence in developing countries. Tasks of the otolaryngologist and phoniatrician in multidisciplinary care, International Congress Series, vol. 1240, 2003, pp. 677–682. [14] M.N. Kotby, A. EL-Shoubary, T. Alloush, N. Gamal, Dysarthria Annual Bulletin of Yufuin Kosenenkin Hospital, Hiese 3 (1992) 373–380. [15] K.J. Golding-Kushner, Standarization for the reporting of nasopharyngoscopy and multi-view videofluoroscopy: a report from an international working group, Cleft Palate J. 27 (1990) 337. [16] M.N. Kotby, E.K. Abdel Haleem, M. Hegazi, I. Safe, M. Zaki, Aspects of assessment and management of velopharyngeal dysfunction in developing countries, Folia Phoniatr. Logop. 49 (1997) 139–146. [17] L. Melika, Stanford Binnet Intelligence Scale (4th Arabic Version), 2nd ed., Victor Kirles Press, Cairo, 1998. [18] A. Abu-Hasseba, Standardization, Translation and Modification of the Preschool Language Scale-4, (Unpublished M.D. Thesis of Phoniatrics, Faculty of Medicine), Ain Shams University, 2011. [19] T. Abou-Elsaad, H. Baz, M. El-Banna, Developing an articulation test for Arabicspeaking school age children, Folia Phoniatr. Logop. 61 (2009) 275–282. [20] B.J. Mcwilliam, R.L. Shelton, H.L. Morris, Cleft Palate Speech, BC Deckers, Philadelphia, 1984. [21] N. Isshiki, I. Honjow, M. Morimoto, Effects of velopharyngeal incompetence upon speech, Cleft Palate J. 5 (1968) 297–310. [22] C.B. Croft, R.J. Shprintzen, S.J. Rakoff, Patterns of velopharyngeal valving in normal and cleft palate subjects: a multi-view of videofluoroscopic and nasendoscopic study, Laryngoscope 91 (1981) 265–271. [23] K. Shahin, Remarks on the speech of Arabic-speaking children with cleft palate: three cases studies, Commun. Disord. 4 (2006) 71–77. [24] K.R. Bzoch, Articulation proficiency and error patterns of preschool cleft palate and normal children, Cleft Palate J. 2 (1965) 340–349. [25] S.D. Brandt, H.L. Morris, The linearity of the relationship between articulation errors and velopharyngeal incompetence, Cleft Palate J. 2 (1965) 176–183. [26] D.W. Warren, Aerodynamic assessments and procedures to determine extent of velopharyngeal inadequacy, in: K.R. Bzoch (Ed.), Communicative Disorders Related to Cleft Lip and Palate, 5th ed., 2004, Aust. Pro-Ed. [27] B.J. McWilliam, An Experimental Study of Some of the Components of Intelligibility of the Speech of Adult Cleft Palate Patients, (Unpublished Ph.D. dissertation), University of Pittsburgh, USA, 1953. [28] S.G. Fletcher, Diagnosing Speech Disorders from Cleft Palate, Grune and Stratton, New York, 1978.
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[29] C. Lawrence, B.J. Philips, A telefluoroscopic study of lingual contacts made by persons with palatal defects, Cleft Palate J. 12 (1975) 85–94. [30] K.T. Moller, Early speech development: the interaction of learning and structure, in: J. Bardach, H.L. Morris (Eds.), Multidisciplinary Management of Cleft Lip and Palate, W.B. Saunders, Philadelphia, 1990, pp. 726–731. [31] F.E. Gibbon, L. Crampin, An electropalatographic investigation of middorsum palatal stops in an adult with repaired cleft palate, Cleft Palate Craniofac. J. 38 (2001) 96–105.
[32] A.R. Brooks, R.L. Shelton, K.A. Youngstrom, Compensatory tongue-palate-postpharyngeal wall relationships in cleft palate, J. Speech Hear. Disord. 30 (1965) 166. [33] B.J. McWiliam, H.L. Morris, R.L. Shelton, The nature of velopharyngeal mechanism, in: B.J. Mcwilliams, H.L. Morris, R.L. Shelton (Eds.), Cleft Palate Speech, BC Decker, Philadelphia, 1990, pp. 197–235. [34] A.E. Aronson, D.M. Bless, Clinical Voice Disorders, 4th ed., Thieme, New York, 2009.
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International Journal of Pediatric Otorhinolaryngology journal homepage: www.elsevier.com/locate/ijporl
The nature of articulation errors in Egyptian Arabic-speaking children with velopharyngeal insufficiency due to cleft palate Tamer Abou-Elsaad a,*, Hemmat Baz a, Omayma Afsah a, Alzahraa Mansy b a b
Phoniatric Units, ORL Departments, Mansoura University Hospitals, Mansoura, Egypt Mansoura General Hospital, Mansoura, Egypt
A R T I C L E I N F O
A B S T R A C T
Article history: Received 26 May 2015 Received in revised form 29 June 2015 Accepted 3 July 2015 Available online 14 July 2015
Even with early surgical repair, the majority of cleft palate children demonstrate articulation errors and have typical cleft palate speech. Objective: Was to determine the nature of articulation errors of Arabic consonants in Egyptian Arabicspeaking children with velopharyngeal insufficiency (VPI). Subjects and methods: Thirty Egyptian Arabic-speaking children with VPI due to cleft palate (whether primary repaired or secondary repaired) were studied. Auditory perceptual assessment (APA) of children speech was conducted. Nasopharyngoscopy was done to assess the velopharyngeal port (VPP) movements while the child was repeating speech tasks. Mansoura Arabic Articulation test (MAAT) was performed to analyze the consonants articulation of these children. Results and conclusion: The most frequent type of articulatory errors observed was substitution, more specifically, backing. Pharyngealization of anterior fricatives was the most frequent substitution, especially for the /s/ sound. The most frequent substituting sounds for other sounds were /// followed by / k/ and /n/ sounds. Significant correlations were found between the degrees of the open nasality and VPP closure and the articulation errors. On the other hand, the sounds (///,/£/,/?/,/n/,/w/,/j/) were normally articulated in all studied group. The determination of articulation errors in VPI children could guide the therapists for designing appropriate speech therapy programs for these cases. ß 2015 Elsevier Ireland Ltd. All rights reserved.
Keywords: Velo-pharyngeal insufficiency Arabic consonants Cleft palate speech Arabic articulation test Child speech disorders Child disability
1. Introduction Velopharyngeal Insufficiency (VPI) means the inability of velum and pharyngeal muscles to produce optimal sphincter-like closure between the oro- and nasopharynx [1]. It may be related to organic or functional etiology but most frequently occurs as a result of cleft palate [2]. Even with early surgical repair, the majority of cleft palate children demonstrate articulation errors and have typical cleft palate speech [3]. Speech characteristics, such as hypernasality, nasal air emission and weak consonants are the direct result of a velopharyngeal or palatal opening. These characteristics have been described as passive speech characteristics [4] or obligatory articulatory errors [5] because they are the product of structural abnormality rather than learned abnormal articulatory behaviors. In contrast, articulatory
* Corresponding author at: Phoniatric Unit, ORL Department, Faculty of Medicine, Mansoura University, Mansoura 35516, Egypt. Tel.: +20 1005192300. E-mail address: [email protected] (T. Abou-Elsaad). http://dx.doi.org/10.1016/j.ijporl.2015.07.003 0165-5876/ß 2015 Elsevier Ireland Ltd. All rights reserved.
errors which occur in response to VPI are considered as active speech characteristics or compensatory articulatory errors. These errors often develop as a response to inadequate intraoral pressure for normal articulation [6]. When the compensatory articulatory errors developed, the manner of production is usually maintained. However, the place of articulation is altered and moved posteriorly to the pharynx or larynx. Examples of these compensatory errors are mid-dorsum palatal stops, velar fricatives, nasal snort, pharyngeal plosives, posterior nasal fricatives and glottal stops [6]. Many of the compensatory sounds do not normally occur in the target language of the child [4,7]. In Arabic, for instance, a glottal stop is a sound of frequent occurrence, while in English; the glottal stop is not normally included within its phonemic inventory. A distinction between obligatory errors and compensatory errors is important to make because the compensatory characteristics are under the patient’s control and can therefore be modified with speech therapy. Obligatory errors are purely the results of abnormal structure and require surgical or prosthetic intervention for correction [6]. Colloquial Egyptian Arabic (CEA) is a dialect of Arabic which consists of 27consonant and eight vowel phonemes with a wide range of places of articulation that span the whole vocal tract from
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lips to glottis [8]. The consonant inventory of CEA includes the primary emphatic phonemes /t/, /d/, /s/, /z/, which causes the Arabic language to be distinguished from the great majority of European languages [9,10]. The Arabic inventory includes back consonants that are either glottal (///), velar (/x/, /g/) or pharyngeal (/9/, /?/) [11]. Kummer [12] believed that the diagnosis of VPI cannot be made until the child begins to produce connected speech and can adequately co-operate with the clinician; which is typically around the age of 3 years. Speech therapy for improvement of articulation placement can be done before the surgery and again after the surgery until errors are corrected [13]. The objective of this study was to determine the nature of articulation errors of Arabic consonants in Egyptian Arabicspeaking children with VPI due to cleft palate in order to highlight the speech problems of these children which would allow for designing appropriate speech therapy programs for them. 2. Subjects and methods Thirty Egyptian Arabic-speaking children with VPI due to cleft palate (whether primary repaired or secondary repaired) were studied. They were 16 females (53.3%) and 14 males (46.7%) with their ages ranged between 3 and 9 years (mean = 5.5 1.61 years) and were uttering at least three-word sentences in order to get reliable speech samples. None of the children received previous speech therapy. Children with sensorineural hearing loss, mental retardation and syndromic cleft palate were excluded from the study. Informed consents were obtained from the parents of the children to participate in the study and the ethical committee of the Mansoura faculty of medicine approved the protocol of the research work. All cases were subjected to history taking, clinical examination, and auditory perceptual assessment (APA) of speech. The latter included reporting on nasality (its type and degree), consonant precision, compensatory articulatory mechanisms (glottal and pharyngeal articulation), facial grimace, audible nasal emission of air and overall intelligibility of speech. All the above elements were graded along a 5-point scale starting with 0 (normal) to 4 (severely affected) [14]. Nasopharyngoscopy was done to assess the velopharyngeal port (VPP) movements while the child was repeating speech tasks including vowels, consonants and automatic speech (counting from 1 to 10) [15]. The pattern of closure of VPP whether coronal, sagittal, circular or circular with passavant’s ridge was specified. Also the degree of closure was determined. The movement of each of the velum, lateral and posterior pharyngeal walls was given a score (0–4) where G0 = the resting (breathing) position, GII = half the distance to the corresponding wall, GIV = the maximum movement reaching and touching the opposite wall [16]. Since the degree of closure was not always consistent in all speech tasks, grading was given as follows: G0, G0–I, GI, GI–II, GII, GII–III, GIII, GIII–IV, and GIV. For examples, if the degree of closure was GI in all speech tasks, the child was given GI. If the degree of closure was GI in vowels but GII in consonants and automatic speech, the child was given GI–II. Psychometric evaluation was done using Stanford Binnet intelligence scale ‘‘4th Arabic version’’[17] for determination of mental age to exclude cases with mental retardation. The Preschool language scale ‘‘4th Arabic Version’’[18] was done for determination of language age. For evaluation of the child’s articulation, Mansoura Arabic Articulation test (MAAT) [19] was performed. After application of MAAT, the consonants were analyzed both individually and after their grouping according to manner and place of articulation into anterior fricatives (including R /s/, /z/, /s/, /z/, / /, /f/), posterior fricatives (including /h/, /?/, /x/, /]/, /£/), anterior plosives (including /b/, /t/, /d/, /d/, /t/), posterior
plosives (including /k/, /g/, and ///), liquids (including /l/, /r/), nasals (including /m/, /n/), and glides (including /j/, /w/). The articulatory errors were labeled as follows: Imprecision. Pharyngealization (when sounds were produced with accompanying constriction of the pharynx). Glottal articulation (when sounds were substituted by /// or /h/). Lateralization (lateral sigmatism). Other substitutions (this term was given for substitution errors other than pharyngealization, glottal articulation and lateralization). Nasal air emission. For calculation of percent errors of sound groups, the percent of children showing the specified error in the individual phonemes constituting the specified group was calculated. Then percent errors of these individual phonemes was summated and divided by the number of these phonemes. For example, calculation of percent errors of anterior fricatives was achieved by summation of percent R of children showing errors in the phonemes /s/, /z/, /s/, /z/, / /, /f/ divided by 6. The results were collected, tabulated, and analyzed using SPSS statistical package Version 15. Qualitative data were presented as numbers and corresponding percentages. The non-parametric Spearman’s rho and parametric Pearson correlation tests were used to measure the relationship between variables. p value was considered statistically significant if <0.05. 3. Results 3.1. Descriptive statistics The results of APA revealed that the majority of the studied children had mild (13 cases) and moderate (10 cases) degrees of open nasality while the rest had slight (5 cases) and severe (2 cases) degrees. One or more of the Arabic consonants were imprecised in 29 cases, nasally air emitted in 26 cases. Pharyngealization of fricatives was observed in 23 cases and glottal articulation in 9 cases. Compensatory facial grimace was observed in 7 cases of the studied children. The overall intelligibility of speech was slightly impaired in 15 cases, mildly impaired in 12 cases and moderately impaired in 3 cases of VPI children (Table 1). Table 1 Description of APA of all studied children (n = 30). Variable
Grade
No of patients
% of patients
Open nasality
G1 G2 G3 G4
5 13 10 2
16.7 43.3 33.3 6.7
Consonant imprecision
G0 (Absent) G1 (Present)
1 29
3.3 96.7
Unintelligibility of speech
G1 G2 G3 G4
15 12 3 0
50.0 40.0 10.0 0
Pharyngealization of fricatives
G0 (Absent) G1 (Present)
7 23
23.3 76.7
Glottal articulation
G0 (Absent) G1 (Present)
21 9
70 30
Nasal air emission
G0 (Absent) G1 (Present)
4 26
13.3 86.7
Facial grimace
G0 (Absent) G1 (Present)
23 7
76.7 23.3
(Slight) (Mild) (Moderate) (Severe)
(Slight) (Mild) (Moderate) (Severe)
T. Abou-Elsaad et al. / International Journal of Pediatric Otorhinolaryngology 79 (2015) 1527–1532 Table 2 Degree of VPP closure of all studied children (n = 30) as revealed by nasoendoscopy.
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Table 3 Pattern of VPP closure of all studied children (n = 30) as revealed by nasoendoscopy.
Degree of VPP closure
Number of patients
% of patients
Pattern of VPP closure
Number of patients
% of patients
G G G G G G G G G
0 0 2 5 5 4 2 12 0
0 0 6.7 16.7 16.7 13.3 6.7 40 0
Coronal Circular Sagittal Circular with Passavant’s ridge
14 10 3 3
46.7 33.3 10.0 10.0
0 0–I I I–II II II–III III III–IV IV
Nasoendoscopic assessments revealed that the majority of children (12 cases, 40%) demonstrated grade III-IV closure of VPP (Table 2). The most frequently observed pattern of VPP closure was coronal pattern (14 cases, 46.7%) and the least observed pattern was sagittal and circular with Passavant’s ridge (3 cases, 10% each) (Table 3). Application of MAAT revealed that substitution was the most frequent type of articulatory errors in all groups of sounds except liquids and glides. The calculated percent of substitutions was 46.12% for anterior plosives, 38.35% for posterior plosives, 68.85% for anterior fricatives, and 12.66% for posterior fricatives. On the other hand, imprecision was the most frequent type of errors observed in the group of liquids, where 23.3% of children demonstrated such error, specifically in /r/ sound. Glides (/j/, / w/) were articulated normally in all studied children. In addition to glides, the consonants (///, /?/, /h/, /n/, /£/) were also normally articulated in all children. A closer look at substitution errors revealed that pharyngealization was the most frequent articulatory error constituting 52.78% of the estimated errors of anterior fricatives (Table 4). The anterior fricatives group was the most frequent group of consonants that were misarticulated (68.85%) and the only group of sounds that showed pharyngealization (Table 4). Predominantly 66.7% of the studied children demonstrated pharyngealization of the /s/ sound (Table 5). The next frequent substitution errors (after pharyngealization of fricatives) observed in the studied children fall under the category ‘‘other substitutions’’. These errors were most frequently observed in /t/ and /d/ sounds (15 cases, 50% each) followed by /d/ (14 cases, 46.7%) and /t/ (13 cases, 43.4%) (Table 5). Considering glottal articulation, the most frequent glottally articulated sounds were the posterior plosives (18.35%) (Table 4). Predominantly /k/ constituted 20% of the glottally articulated sounds (Table 5). Lateralization was only observed in anterior fricatives (8.9%) (Table 4). Predominantly /k/ sounds constituted 16.7% of the lateralized sounds (Table 5). Nasal air emission was most observed in anterior fricatives (56.7%) (Table 4). At the level of individual phonemes (Table 5), /s/ was the most R frequent substituted sound (86.7%), followed by / / (83.3%) then / z/ and /s/ (70.6% each).
Analysis of substitutions among individual phonemes (in relation to each other) revealed that the most frequent substituting sound was /// which substituted for 14 sounds (glottal articulation) (Table 5). Regarding ‘‘other substitutions’’, /k/ and /n/ were the most frequent substituting sounds, especially for anterior sounds. The labial plosive /b/ was most frequently substituted by /m/ (30%) (Table 6). The compensatory articulation errors thus revealed in the study sample include pharyngealization of the anterior fricatives, glottal articulation of both stops and fricatives, and nasal fricatives (the substitution of /f/ by /n/) (Tables 4 and 6). 3.2. Correlative analysis Positive significant correlations were found between the degree of open nasality and the articulatory errors of anterior plosives, posterior plosives, anterior fricatives, posterior fricatives (p < 0.01) and liquids (p < 0.05). On the other hand, non-significant correlation was found between the degree of open nasality and nasals (p > 0.05) (Table 7). Negative significant correlations were found between the degree of nasoendoscopic closure of VPP during automatic speech and the articulation errors of the anterior plosives, posterior plosives, anterior fricatives (p < 0.01). On the other hand, nonsignificant correlations were found between the degree of VPP closure during automatic speech and the articulation errors of the posterior fricatives, nasals and liquids (p > 0.05) (Table 8). No correlations could be statistically conducted with the glides as they were normally articulated in all studied group. 4. Discussion Oral consonants necessitate closed velopharyngeal valve in order to build up the necessary intra-oral pressure for their proper production. Patients with VPI cannot produce this pressure. So these difficulties; with the anatomical defect of cleft patient, constitute the base of the articulatory problems in VPI [20]. The current study was conducted on 30 Egyptian children with VPI following repair of cleft palate, aiming at identifying the nature of their articulation errors for proper decision-making of management. The results of the APA revealed that the majority of studied children had mild and moderate degrees of open nasality.
Table 4 Description of articulatory errors according to place and manner of articulation.
Normal Imprecision Pharyngealization Glottal articulation Lateralization Other substitutions Total substitutions Nasal air emission
Anterior plosives
Posterior plosives
Anterior fricatives
Posterior fricatives
Liquids
Nasals
Glides
36.66% 6.7% 0 9.45% 0 36.67% 46.12% 20%
68.9% 8.3% 0 18.35% 0 20% 38.35% 16.7%
26.7% 4.45% 52.78% 3.3% 8.9% 3.87% 68.85% 56.7%
84% 3.34% 0 4% 0 8.66% 12.66% 0
66.65% 23.3% 0 0 0 21.65% 21.65% 0
98.35% 0 0 0 0 3.3% 3.3% 0
100% 0 0 0 0 0 0 0
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Table 5 Description of articulatory errors in misarticulated sounds in all studied children (n = 30).a Misarticulated sound
Imprecision
/b/ /t/ /g/ /x/ /d/ /r/ /z/ /s/ /R/ /s/ /d/ /t/ /z/ /]/ /f/ /k/ /l/ /m/
0 3 4 3 2 7 2 0 0 0 3 4 2 2 4 1 0 0
a
(10%) (13.3%) (10%) (6.7%) (23.3%) (6.7%)
(10%) (13.3%) (6.7%) (6.7%) (13.3%) (3.3%)
Substitutions
Nasal emission
Pharyngealization
Glottal articulation
Lateralization
Other substitutions
Total substitutions
0 0 0 0 0 0 18 20 17 19 0 0 17 0 4 0 0 0
0 5 5 2 5 0 1 1 1 1 3 4 1 4 1 6 0 0
0 0 0 0 0 0 3 4 5 2 0 0 2 0 0 0 0 0
9 15 10 4 14 10 1 1 2 1 15 13 1 9 1 2 3 1
9 20 15 6 19 10 23 26 25 23 18 17 21 13 6 8 3 1
(60%) (66.7%) (56.7%) (63.3%)
(56.7%) (13.3%)
(16.7%) (16.7%) (6.7%) (16.7%) (3.3%) (3.3%) (3.3%) (3.3%) (10%) (13.3%) (3.3%) (13.3%) (3.3%) (20%)
(10%) (13.3%) (16.7%) (6.7%)
(6.7%)
(30%) (50%) (33.3%) (13.3%) (46.7%) (33.3%) (3.3%) (3.3%) (6.7%) (3.3%) (50%) (43.4%) (3.3%) (30%) (3.3%) (6.7%) (10%) (3.3%)
(30%) (66.7%) (50%) (20%) (63.3%) (33.3%) (70.6%) (86.7%) (83.3%) (70.6%) (60%) (56.7%) (70%) (43.3%) (20%) (20.7%) (10%) (3.3%)
2 2 5 0 0 0 3 3 3 3 1 1 3 0 2 0 0 0
(6.7%) (6.7%) (16.7%)
(10%) (10%) (10%) (10%) (3.3%) (3.3%) (10%) (6.7%)
Values are expressed as number of children showing the error (%).
Nasoendoscopic assessments of these children demonstrated grade III–IV closure of VPP. These results agree with that of Isshiki [21], who found that milder degrees of open nasality coincide with smaller velopharyngeal opening. The most frequent observed pattern of VPP closure was coronal pattern (46.7%). This finding is agreeable with that of Croft et al. [22] who found that coronal pattern was the commonest pattern of closure, representing 55% of their patients.
Table 6 Description of ‘‘other substitutions’’ in all studied children (n = 30). Substituted sound
Substituting sound
Number of children (%)
/b/ /t/
/m/ /k/ /n/ /j/ /k/ /n/ /£/ /k/ /n/ /t/ /g/ /j/ /l/ /n/ /w/ /j/ /£/ /£/ /£/ /s/ /£/ /k/ /g/ /n/ /q/ /t/ /n/ /£/ /x/ /£/ /?/ /n/ /n/ /j/ /n/ /n/
9 13 1 1 9 1 4 6 2 3 1 6 2 4 2 2 1 1 1 1 1 3 3 3 4 2 2 1 7 1 1 1 1 1 3 1
/g/ /x/ /d/
/r/
/z/ /s/ /k/ /S/ /d/
/z/
/f/ /k/ /l/ /m/
(30%) (43.4%) (3.3%) (3.3%) (30%) (3.3%) (13.3%) (20%) (6.7%) (10%) (3.3%) (20%) (6.7%) (13.3%) (6.7%) (6.7%) (3.3%) (3.3%) (3.3%) (3.3%) (3.3%) (10%) (10%) (10%) (13.3%) (6.7%) (6.7%) (3.3%) (23.3%) (3.3%) (3.3%) (3.3%) (3.3%) (3.3%) (10%) (3.3%)
The sounds (///, /£/, /?/, /n/, /w/, /j/) were normally articulated in all studied group since most of those consonants’ constrictions are below the velum. Similar results were obtained by Shahin [23] and Bzoch [24]. On the other hand, we observed the predominance of articulation errors among the anterior fricatives in the current study. This finding is similar to the result of Brandt et al. study [25] who reported that fricatives were the most frequent misarticulated group of sounds in their patients. The current study revealed non-significant correlation between the degree of open nasality and articulatory errors of nasals (p > 0.05). The possible explanation, as stated by Kummer [6], is that nasal sounds occur with open valve and consequently not affected by VPI. On the other hand, articulatory errors of both plosives and anterior fricatives were significantly correlated with the degree of open nasality because these sounds necessitate VPP closure for their production. According to warren [26], the inability to generate and/or maintain adequate levels of intraoral pressure for production of plosion or friction may lead to the development of atypical places of production. This explanation also accounts for the negative significant correlation between the degree of nasoendoscopic closure and articulation errors of plosives and anterior fricatives. Similar to the result of McWilliams [27] study, /s/ sound was the most frequent misarticulated sound by cleft palate patients. Generally, the sibilant fricatives (including /s/) are more distorted than the non-sibilants in these patients because the former have a more strident quality and longer duration than the latter. Also, as
Table 7 Correlation between the degree of open nasality and consonant misarticulation. Consonant misarticulation
Open nasality degree p
r Anterior plosives Posterior plosives Anterior fricatives Posterior fricatives Liquids Nasals Glides
**
0.486 0.644** 0.522** 0.486** 0.407* 0.074 0
0.006 0.000 0.003 0.007 0.026 0.697 0
Non-parametric spearman’s rho correlation and Wilcoxon signed Ranks test. * p < 0.05. ** p < 0.01.
T. Abou-Elsaad et al. / International Journal of Pediatric Otorhinolaryngology 79 (2015) 1527–1532 Table 8 Correlation between the degree of nasoendoscopic closure of VPP during automatic speech and consonant misarticulation. Consonant misarticulation
Closure with automatic speech r
Anterior plosives Posterior plosives Anterior fricatives Posterior fricatives Liquids Nasals Glides
p 0.484** 0.506** 0.476** 0.220 0.346 0.168 0
0.007 0.004 0.008 0.243 0.061 0.376 0
Non-parametric spearman’s rho correlation test and Wilcoxon Signed Ranks test. ** p < 0.01.
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more specifically, backing. Pharyngealization of anterior fricatives was the most frequent substitution, especially for the /s/ sound. The most frequent substituting sounds for other sounds were /// followed by /k/ and /n/ sounds. Significant correlations were found between the degrees of the open nasality and VPP closure and the articulation errors. On the other hand, the sounds (///, /£/, /?/, /n/, / w/, /j/) were normally articulated in all studied group. The determination of articulation errors in VPI children could guide the therapists for designing appropriate speech therapy programs for these cases. Conflicts of interest None.
stated by Fletcher [28], sibilant sounds require precise placement and control of the tongue where it is positioned in contact with the alveolar margins laterally and at a specified distance from the incisor teeth anteriorly. The sibilants also require formation of a medial groove anteriorly between the blade of the tongue and the alveolar ridge. The airstream is then diverted at the VPP from where it flows under pressure through the groove and turbulence space between the tongue and the teeth. The substitution of alveolar sound /t/ by the velar sound /k/ was observed in 43.3% of the studied children. This finding was described by some authors (e.g. Lawrence and Philips [29]; Moller [30] as a common general error pattern in speakers with repaired cleft palate, and was referred to by Gibbon and Crampin [31] as a ‘retracted’ or ‘backed’ tongue. The back tongue position can help to push the velum upward to assist with closure as a compensatory strategy for VPI [32,33], and allows the individual to impound air pressure in the back of the oral cavity. The current study also revealed preponderance of glottal articulation (the glottal stop ///) and the velar stop /k/ as the most common compensatory articulation patterns used by Arabic speaking children with VPI due to cleft palate substituting other consonant sounds. In English, on the other hand, cleft palate children usually use the glottal stop, the pharyngeal stop, the posterior nasal fricative and the velar fricative as posterior placements [34]. Substitutions not only involved the place of articulation, but involved the manner of articulation as well. In the current study, substitution of some oral sounds by nasal sounds (/m/, /n/) was observed in 30%, 20% of the studied children respectively. Such substitutions are considered obligatory errors [6]. This finding could be explained by the abnormal function of the velopharyngeal mechanism where cleft palate speakers compensate for oral sounds by sounds that are easily produced. Thus, attempts to produce voiced plosives may result in the production of their nasal cognates. Even voiceless plosives and other oral sounds can be nasalized due to the open VPP [6]. The labial plosive /b/ was most frequently substituted by /m/ (30%). This error is considered to be due to the fact that /b/ and /m/ are almost identical in articulatory mechanism except for the requirement of velopharyngeal closure during /b/ [21]. The previously mentioned articulation errors in Egyptian Arabic-speaking VPI children should be considered in their speech therapy. The goal of the therapy is to correct placement (and sometimes manner) of production. A further study is needed to examine different approaches for many of articulation errors in Arabic-speaking children with VPI. 5. Conclusion The most frequent type of articulation errors observed in Arabic-speaking VPI children due to cleft palate was substitution,
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