Elsevier

Journal of Voice

Volume 18, Issue 3, September 2004, Pages 354-362
Journal of Voice

Vocal quality characteristics in children with cleft palate: a multiparameter approach

https://doi.org/10.1016/j.jvoice.2003.12.006Get rights and content

Abstract

The main purpose of the present study was to examine the vocal quality and to investigate the effects of gender on vocal quality in 28 children with a unilateral or bilateral cleft palate. In this study, the vocal quality was determined using videolaryngostroboscopic and perceptual evaluations, aerodynamic, voice range, acoustic, and dysphonia severity index (DSI) measurements. The DSI is based on the weighted combination of four voice measurements and ranges from +5 to −5 for, respectively, normal and severely dysphonic voices. Additional objectives were to compare the vocal quality characteristics of children with cleft palate with the available normative data and to investigate the impact of the cleft type on vocal quality. Gender-related vocal quality differences were found. The male cleft palate children showed an overall vocal quality of +0.62 with the presence of a perceptual slight grade of hoarseness and roughness. The female vocal quality had a DSI value of +2.4 reflecting a perceptually normal voice. Irrespective of the type of cleft, all subjects demonstrated a significantly lower DSI-value in comparison with the available normative data. The results of the present study have provided valuable insights into the vocal quality characteristics of cleft palate children.

Introduction

To minimize hypernasality and to reach a given voice intensity, several authors1., 2., 3., 4. hypothesized that speakers with velopharyngeal disorders expend stronger adductory force on their laryngeal structures. To provide a constriction inferior to the inadequately functioning velopharyngeal port during phonation, a possible forced use of the vocal cords might lead to more voice disorders in speakers with clefts compared with speakers without clefts. Several authors described the laryngeal disorders or vocal quality of speakers with cleft palate. Table 1, Table 2 summarized the most cited organic and functional disorders in cleft palate patients.

A large variety of organic and functional voice disorders in speakers with clefts have been described. The summary in Table 2 showed also contradictory findings regarding the voice characteristics in children. Whereas Tarlow and Saxman23 reported a normal F0 fundamental frequency (F0), other authors found higher F0 in males,15 lower F0 in females,19., 20. or excessive high or low habitual pitch.9 Whereas some authors17., 18., 19., 20., 21., 22. describe the subjective pattern of vocal behavior as soft or aspirated, other authors found the voice strangled with excessive tension.9., 10., 11., 12., 13., 14., 15., 16., 17., 18., 19., 20., 21., 22. Thus far, most studies concentrated on the subjective patterns of vocal behavior that may be symptomatic for a velopharyngeal disorder. Objective studies on vocal quality in subjects with cleft palate are sparse. Few studies reported measured acoustic evidence of vocal pathology in cleft palate subjects. In a study of Leder and Lerman,3 the spectrograms of speakers with cleft palate revealed inappropriate vocal fold adduction during stop consonant production. Zajac and Linville25 and Lewis et al26 reported higher frequency perturbation (jitter). To the best of our knowledge, no objective studies have focused on vocal quality in cleft palate subjects based on a multiparameter approach by means of the Dysphonia Severity Index (DSI). The aim of the present study was to determine the vocal quality and to investigate the effects of gender on vocal quality in children with cleft palate. In this study, the vocal quality was determined using videolaryngostroboscopic and perceptual evaluations, aerodynamic, voice range, acoustic, and DSI measurements. To establish an objective and quantitative measure for perceived vocal quality, the DSI is based on the weighted combination of the following selected set of voice measurements: highest frequency (F0-high in Hz), lowest intensity (I-low in dB), maximum phonation time (MPT in s), and jitter (%). The DSI ranges from +5 to −5 for, respectively, normal and severely dysphonic voices. The more negative the patient;s index, the worse is the vocal quality.27 As far we could ascertain, knowledge regarding how gender affects vocal quality in children with cleft palate is nonexistent. As there are many more boys implicated in screaming and noise making than girls,28., 29. a more negative DSI-value combined with perceptual voice symptoms for boys was expected. An additional objective was to compare the vocal quality characteristics of children with cleft palate with the available noncleft normative data. The authors hypothesized that children with cleft palate have an increased risk for voice disorders because of the more intensive vocal tract activities compared with noncleft subjects. A more negative DSI and dysphonic symptoms compared with normative data are needed to support this hypothesis. A second additional objective of this study was to investigate the impact of the cleft type [unilateral cleft lip and palate (CLP) and bilateral cleft lip and palate (BCLP)] on vocal quality. It was hypothesized that the severity of the voice disorders increases with the severity of the cleft type.

Section snippets

Cleft palate subjects

Thirty-one children with cleft palate, all patients of the Ghent University Hospital Craniofacial Center, were selected to participate in this study. None of them had clefts associated with syndromes, had undergone secondary pharyngeal surgery, and had a cognitive deficiency, neuromotor dysfunction, and a hearing threshold above 20 dB in the worst ear. Subjects with a pathology of the nose (nasal septal deviation in 1 subject) and subjects suffering from common cold on the day of testing (2

Methods

Subjective (videolaryngolostroboscopic and auditory perceptual evaluation) as well as objective (aerodynamic, voice range, acoustic and DSI measurements) assessment techniques were used to determine vocal quality in this population.

Vocal pathology and vocal quality of the cleft palate subjects

The results of the videolaryngostroboscopic evaluation of the cleft palate subjects are presented in Table 3. A laryngeal pathology was observed in 32% (9/28) of the cleft palate subjects. Eleven percent (3/28; 2 males, 1 female) showed bilateral vocal nodules, and 11% (3/28;1 male, 2 females) showed a muscle tension pattern (MTP) type 1. Edema was observed in 7% (2/28; 1 male, 1 female), and inflammation of the vocal folds was observed in 3% (1/28; 1 female) of the subjects.

The results of the

Discussion

Several studies 3., 5., 6., 7., 8., 9., 10., 11., 12., 13., 14., 15., 16., 17., 18., 19., 20., 21., 22., 23., 24. investigated the voice characteristics in subjects with a velopharyngeal insufficiency. The picture that emerges from the extent investigations showed wide variation and even contradictory findings. None of these studies, however, presents a detailed gender-related objective measure of vocal quality based on a multiparameter approach.

The present study investigated the vocal quality

Conclusion

The results of the present study have provided valuable insights into the vocal quality of cleft palate children with a mean age of 9.9 years. Irrespective of the type of cleft, all cleft palate speakers demonstrated a significantly lower DSI-value in comparison with the available normative data. In addition, a significantly lower F0 and significantly less maximum pitch (F-high) and low-intensity (I-low) capacities were observed. Bilateral vocal nodules and a muscle tension pattern type I were

Acknowledgements

The authors wish to express their deep appreciation to the children with a cleft palate who have given their time and effort to this research. We gratefully thank the contribution of Alexandra Muylaert during the investigations.

References (43)

  • M. De Bodt et al.

    Test-Retest study of the GRBAS Scale: the influence of experience and professional background on perceptual rating of voice quality

    J Voice

    (1997)
  • F.L. Wuyts et al.

    Normative voice range profiles of untrained boys and girls

    J Voice

    (2002)
  • J. Curtis

    Acoustics of speech production and nasalization

  • S. Hamlet

    Vocal compensation: an ultrasonic study of vocal vibration in normal and nasal vowels

    Cleft Palate J

    (1973)
  • S. Leder et al.

    Some acoustic evidence for vocal abuse in adult speakers with repaired cleft palate

    Laryngoscope

    (1985)
  • A.E. Aronson

    Nasal resonatory disorders

  • E. McDonald et al.

    Cleft Palate Speech: An integration of research and clinical observation

    J Speech Hear Disord

    (1951)
  • M. Berry et al.

    Speech Disorders

    (1956)
  • B.J. McWilliams et al.

    Diagnostic implications of vocal cord nodules in children with cleft palate

    Laryngoscope

    (1969)
  • B.J. McWilliams et al.

    Vocal cord abnormalities in children with velopharyngeal valving problems

    Laryngoscope

    (1973)
  • L.L. D'Antonio et al.

    Laryngeal/voice findings in patients with velopharyngeal dysfunction

    Laryngoscope

    (1988)
  • G. Seth et al.

    Speech in childhood. Its development and disorders

    (1935)
  • L. Cobb et al.

    An analysis of the speech difficulties of 56 cleft palate and harelip cases

    Arch Speech

    (1936)
  • W. Ritchie

    Cleft palate: a correlation of anatomic and functional results following operation

    Arch Surg

    (1937)
  • H. Westlake

    Understanding the cleft palate child

    Quart J Speech

    (1953)
  • H. Westlake et al.

    Cleft Palate

    (1966)
  • D.R. Dickson

    An acoustic study of nasality

    J Speech Hear Res

    (1962)
  • A.R. Brooks et al.

    Incidence of voice disorders other than nasality in cleft palate children

    Cleft Palate Bull

    (1963)
  • K.R. Bzoch

    The effects of specific pharyngeal flap operation upon the speech of 40 cleft palate persons

    J Speech Hear Disord

    (1964)
  • K.R. Bzoch

    Etiological factors related to cleft palate speech

  • Flint R. Fundamental vocal frequency and severity of nasality in cleft palate speakers. Master's Thesis, University of...
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