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  • 1.
    Brunnegård, Karin
    Umeå University, Faculty of Medicine, Department of Clinical Sciences, Speech and Language Therapy.
    Evaluation of nasal speech: a study of assessments by speech-language pathologists, untrained listeners and nasometry2008Doctoral thesis, comprehensive summary (Other academic)
    Abstract [en]

    Excessive nasal resonance in speech (hypernasality) is a disorder which may have negative communicative and social consequences for the speaker. Excessive nasal resonance is often associated with cleft lip and palate, velopharyngeal impairment, dysarthria or hearing impairment. Evaluation of hypernasality has proved to be a challenge in the clinic and in research. There are questions regarding the accuracy and reliability of auditory perceptual evaluations of nasal speech, and whether instrumental measures can be used to improve the reliability of clinical evaluation. There is also the question of whether clinical evaluation reflects the impact of hypernasality in a speaker’s everyday life.

    The purpose of this thesis was to evaluate the extent of reliability problems connected with auditory perceptual assessment of nasality in speech, to explore whether they might interfere with treatment decisions or have an impact in the everyday life of patients, and whether they can be effectively diminished by the use of nasometry.

    Speakers with cleft lip and palate or velopharyngeal impairment formed the basis of the clinical population used in this study. Speech samples from 52 of these speakers, along with samples from a reference population of 21 speakers who did not have cleft palate, velopharyngeal impairment or speech disorders were used in perceptual evaluation tasks. Fourteen speakers from the clinical population and 11 from the reference population also underwent nasometric evaluation. A further reference population of 220 children from three Swedish cities, whose ages were consistent with those used for clinical checks of children born with cleft palate were assessed with nasometry to establish normative data for the Nasometer™. Perceptual speech assessments were conducted on hyper- and hyponasality, as well as audible nasal air emission and/or nasal turbulence, using 5-point ordinal scales. Listeners were SLPs experienced in the evaluation of cleft palate speech, non-expert SLPs and untrained listeners. Listening assessments were performed from audio recorded speech samples assembled in random order. Nasometry measures were made on three speech passages each with specific phonetic content, using the Nasometer™, model II.

    Perceptual evaluation Results showed that for hypernasality assessment, 15% of hypernasality assessments had disagreements between expert SLPs that were potentially important for clinical decisions, as did 6% of assessments for audible nasal air emission and/or nasal turbulence. For nasality problems, a comparison of expert and untrained listeners showed that they generally agreed on which speakers were hypernasal and on the ranking of nasal speakers. All speakers that had been rated with moderate to severe hypernasality by expert listeners were considered by the untrained listeners as having a serious enough speech disorder to call for intervention. However, in the case of audible nasal air emission and/or nasal turbulence the expert listeners were more prone to notice this feature than the untrained listeners.

    Instrumental evaluation The development of normative values for the three Swedish passages for the NasometerTM (comparable to normative values in other languages) has provided a basis for use of instrumental measures in Swedish clinics, oral sentences mixed sentences nasal sentences. The measures showed no significant differences due to city, gender or age within an age range of 4-10 years. When nasometry measures were compared with perceptual evaluation of speech samples from the same speakers, all correlations were moderate to good for expert SLPs and non-expert SLPs. The difference between correlations was significantly higher for expert SLPs than for untrained listeners.

    Reliability figures for perceptual assessments for expert SLP listeners indicated that there were some cases where lack of reliability could affect clinical decision making. However, in the main, judgements of nasality problems made by clinicians had everyday validity. They reflected the impressions of the everyday listener, especially in regard to the need for intervention. The study also indicates that now that Swedish norms are available, the Nasometer™ might be useful as a complement to auditory perceptual clinical speech assessments in Swedish cleft palate clinics in order to improve reliability of clinical assessment.

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  • 2.
    Brunnegård, Karin
    et al.
    Umeå University, Faculty of Medicine, Department of Clinical Sciences, Speech and Language Therapy.
    Lohmander, Anette
    A cross-sectional study of speech in 10-year-old children with cleft palate: results and issues of rater reliability2007In: Cleft Palate Craniofacial Journal, ISSN 1055-6656, Vol. 44, no 1, p. 33-44Article in journal (Refereed)
    Abstract [sv]

    OBJECTIVES: To describe speech based on perceptual evaluation in a group of 10-year-old children with cleft palate. A secondary aim was to investigate the reliability of speech-language pathologists' perceptual assessment of cleft palate speech. DESIGN: Retrospective cross-sectional study in children with cleft palate. External raters made assessments from randomized speech recordings. SUBJECTS: Thirty-eight children with unilateral cleft lip and palate (UCLP) or cleft palate only (CPO) and 10 children in a comparison group. MAIN OUTCOME MEASURES: Ratings of hypernasality, hyponasality, audible nasal air leakage, weak pressure consonants, and articulation. Exact agreement and weighted kappa values were used for reliability. RESULTS: Hypernasality was found in 25% of children with a cleft of the soft palate (CSP), 33% of children with a cleft of the hard and soft palate (CHSP), and 67% of children with a UCLP. Similar results were found for audible nasal air leakage. Articulation errors were found in 6% of the CHSP group and 25% of the UCLP group, whereas no child in the CSP group had articulation errors. The reliability was moderate to good for different variables, with lowest values for hypernasality. CONCLUSIONS: Speech results in this series seem less satisfactory than those reported in other published international studies, but it is difficult to draw any certain conclusions about speech results because of large methodological differences. Further developments to ensure high reliability of perceptual ratings of speech are called for.

  • 3.
    Brunnegård, Karin
    et al.
    Umeå University, Faculty of Medicine, Department of Clinical Sciences, Speech and Language Therapy.
    Lohmander, Anette
    van Doorn, Jan
    Umeå University, Faculty of Medicine, Department of Clinical Sciences, Speech and Language Therapy.
    Comparison between perceptual assessments of nasality and nasalance scores2012In: International journal of language and communication disorders, ISSN 1368-2822, E-ISSN 1460-6984, Vol. 47, no 5, p. 556-566Article in journal (Refereed)
    Abstract [en]

    Background: There are different reports of the usefulness of the Nasometer™ as a complement to listening, often as correlation calculations between listening and nasalance measurements. Differences between findings have been attributed to listener experience and types of speech stimuli.

    Aims: To compare nasalance scores from the Nasometer with perceptual assessments, for the same and different Swedish speech stimuli, using three groups of listeners with differing levels of experience in judging speech nasality. Methods & Procedures: To compare nasalance scores and blinded listener ratings of randomized recordings using three groups of listeners and two groups of speakers. Speakers were either classified as having hypernasal speech or speech with typical speech resonance. Listeners were speech-language pathologists (SLPs) working predominantly with resonance disorders, other SLPs and untrained listeners.

    Outcomes & Results: Correlations (r(s) ) between hypernasality ratings and nasalance scores for each listener group and speech stimuli were calculated. For both groups of SLPs all correlations between perceptual ratings and nasalance scores were significant at p= 0.01. The correlations between the nasalance scores and ratings by listeners in the SLP groups were higher than those for the untrained listener group regardless of stimulus type. Post-hoc Mann-Whitney U-tests showed that the only difference that was significant was expert SLP group versus untrained listener group. Secondly, correlations between perceptual ratings and oral stimulus nasalance scores were higher when the perceptual ratings were based on spontaneous speech rather than on the oral stimulus. However, a Wilcoxon signed rank test showed that the difference was not significant. A third finding was that correlations between oral stimulus nasalance scores and perceptual scores were higher than those between mixed stimulus nasalance scores and perceptual scores. A Wilcoxon signed rank test showed that the difference was significant.

    Conclusions & Implications: The Nasometer might be useful for the SLP with limited experience in assessing resonance disorders in differentiating between hyper- and hyponasality. With listener reliability for ratings of hypernasality still being an issue, the use of a nasalance score as a complement to the perceptual evaluation will also aid the expert SLP. It will give an alternative way of quantifying speech resonance and might help in especially hard to judge cases.

  • 4.
    Brunnegård, Karin
    et al.
    Umeå University, Faculty of Medicine, Department of Clinical Sciences, Speech and Language Therapy.
    Lohmander, Anette
    van Doorn, Jan
    Umeå University, Faculty of Medicine, Department of Clinical Sciences, Speech and Language Therapy.
    Untrained listeners’ ratings of speech disorders in a group with cleft palate: a comparison with speech and language pathologists’ ratings2009In: International journal of language and communication disorders, ISSN 1368-2822, E-ISSN 1460-6984, Vol. 44, no 5, p. 656-674Article in journal (Refereed)
    Abstract [en]

    Background: Hypernasal resonance, audible nasal air emission and/or nasal turbulence, and articulation errors are typical speech disorders associated with the speech of children with cleft lip and palate. Several studies indicate that hypernasal resonance tends to be perceived negatively by listeners. Most perceptual studies of speech disorders related to cleft palate are carried out with speech and language pathologists as listeners, whereas only a few studies have been conducted to explore how judgements by untrained listeners compare with expert assessments. These types of studies can be used to determine whether children for whom speech and language pathologists recommend intervention have a significant speech deviance that is also detected by untrained listeners.

    Aims: To compare ratings by untrained listeners with ratings by speech and language pathologists for cleft palate speech.

    Methods & Procedures: An assessment form for untrained listeners was developed using statements and a five-point scale. The assessment form was tailored to facilitate comparison with expert judgements. Twenty-eight untrained listeners assessed the speech of 26 speakers with cleft palate and ten speakers without cleft in a comparison group. This assessment was compared with the joint assessment of two expert speech and language pathologists.

    Outcomes & Results: Listener groups generally agreed on which speakers were nasal. The untrained listeners detected hyper- and hyponasality when it was present in speech and considered moderate to severe hypernasality to be serious enough to call for intervention. The expert listeners assessed audible nasal air emission and/or nasal turbulence to be present in twice as many speakers as the untrained listeners who were much less sensitive to audible nasal air emission and/or nasal turbulence.

    Conclusions & Implications: The results of untrained listeners' ratings in this study in the main confirm the ratings of speech and language pathologists and show that cleft palate speech disorders may have an impact in the everyday life of the speaker.

  • 5.
    Brunnegård, Karin
    et al.
    Umeå University, Faculty of Medicine, Department of Clinical Sciences, Speech and Language Therapy.
    van Doorn, Jan
    Umeå University, Faculty of Medicine, Department of Clinical Sciences, Speech and Language Therapy.
    Normative data on nasalance scores for Swedish as measured on the Nasometer™ II: influence of regional dialect, gender and age2009In: Clinical linguistics and phonetics, ISSN 1368-2822, Vol. 23, no 1, p. 58-69Article in journal (Refereed)
    Abstract [en]

    This study was conducted to establish normative nasalance values for Swedish speaking children as measured with the Nasometer™ II, and to investigate differences due to regional dialect, gender, and age. Two hundred and twenty healthy children aged 4-5, 6-7, and 9-11 years were included. Group mean nasalance scores for four speech stimuli were calculated and compared. There were no significant differences due to dialect or gender for children in the study. For age there was a significant difference on nasal sentences between the youngest group of children and the other two groups, age 4-5 vs age 6-7 (t = -2.844, p = .006) and for age 4-5 vs age 9-11 (t = -2.888, p = .005). The results from this study have both clinical significance for Swedish SLPs working with resonance disorders, and theoretical significance for linguists studying features of dialects and languages.

  • 6. Klintö, Kristina
    et al.
    Brunnegård, Karin
    Umeå University, Faculty of Medicine, Department of Clinical Sciences, Speech and Language Therapy.
    Havstam, Christina
    Appelqvist, Malin
    Hagberg, Emilie
    Taleman, Ann-Sofie
    Lohmander, Anette
    Speech in 5-year-olds born with unilateral cleft lip and palate: a Prospective Swedish Intercenter Study2019In: Scandinavian Journal of Plastic and Reconstructive Surgery and Hand Surgery, ISSN 2000-656X, E-ISSN 2000-6764, Vol. 53, no 5, p. 309-315Article in journal (Refereed)
    Abstract [en]

    Studies on the impact of cleft palate surgery on speech with stringent methodology are called for, since we still do not know the best timing or the best method for surgery. The purpose was to report on speech outcome for all Swedish-speaking 5-year-olds born with a non-syndromic unilateral cleft lip and palate (UCLP), in 2008-2010, treated at Sweden's six cleft palate centres, and to compare speech outcomes between centres. Speech was assessed in 57 children with percent consonants correct adjusted for age (PCC-A), based on phonetic transcriptions from audio recordings by five independent judges. Also, hypernasality and perceived velopharyngeal function were assessed. The median PCC-A for all children was 93.9, and medians in the different groups varied from 89.9 to 96.8. In the total group, 9 children (16%) had more than mild hypernasality. Twenty-two children (38.5%) were perceived as having competent/sufficient velopharyngeal function, 25 (44%) as having marginally incompetent/insufficient velopharyngeal function, and 10 children (17.5%) as having incompetent/insufficient velopharyngeal function. Ten children were treated with secondary speech improving surgery and/or fistula surgery. No significant differences among the six groups, with eight to ten children in each group, were found. The results were similar to those in other studies on speech of children with UCLP, but poorer than results in normative data of Swedish-speaking 5-year-olds without UCLP. Indications of differences in frequency of surgical treatment and speech treatment between centres were observed.

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  • 7.
    van Doorn, Jan
    et al.
    Umeå University, Faculty of Medicine, Department of Clinical Sciences, Speech and Language Therapy.
    Bergh, Ida
    Umeå University, Faculty of Medicine, Department of Clinical Sciences, Speech and Language Therapy.
    Brunnegård, Karin
    Umeå University, Faculty of Medicine, Department of Clinical Sciences, Speech and Language Therapy.
    Optimizing stimulus length for clinical nasalance measures in Swedish2009In: Clinical Linguistics & Phonetics, ISSN 0269-9206, E-ISSN 1464-5076, Vol. 22, no 4-5, p. 355-361Article in journal (Refereed)
    Abstract [en]

    Standardized passages used for speech nasalance measures may be too long for clinical use with very young or non-compliant patients. The aim of this study was to establish whether nasalance scores from shorter sections of three Swedish speech stimuli were equivalent to those from their corresponding whole stimulus. Nasalance recordings for three Swedish speech stimuli (oral, nasal and oronasal) were obtained from 29 typically developing Swedish children (7-11 years). Cumulative sentence combinations were evaluated for equivalence to their respective whole passages according to two different criteria: one based on t-testing and the other on cumulative frequencies of score differences. Results showed that shorter sequences of sentences could be considered equivalent to the whole passage for the oral and nasal stimuli, provided that the sentences were sequenced in order of increasing difference from the whole stimulus score and that those sentences with scores significantly different from the whole passage score were not included.

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