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The Nasality Severity Index 2.0 The Nasality Severity Index 2.0 Adaptation and application of a new multiparametric approach to hypernasality Kim Bettens 2016 Prof. dr. Kristiane Van Lierde Prof. dr. Floris Wuyts Faculty of Health Sciences and Medicine Department of Speech, Language and Hearing Sciences The Nasality Severity Index 2.0: Adaptation and application of a new multiparametric approach to hypernasality Kim Bettens Supervisor: Prof. dr. Kristiane Van Lierde Co-supervisor: Prof. dr. Floris Wuyts Thesis submitted to fulfill the requirements for the degree of Doctor in Health Sciences 2016 Examining board Prof. Dr. J. Van De Voorde (Chair) Prof. Dr. P. Corthals Prof. Dr. E. De Leenheer Prof. Dr. G. De Pauw Prof. Dr. E. Gerrits Prof. Dr. E. Manders Prof. Dr. P. Van Cauwenberghe Cover design Ellen Creve | [email protected] Printing University Press | Leegstraat 15 | 9060 Zelzate | Belgium Tel: +32 (0)9 342 72 25 | [email protected] www.universitypress.be ©Kim Bettens, Ghent, Belgium All rights reserved. No part of this work may be reproduced in any form or by any means, electronically, mechanically, by print, or otherwise, without prior written permission by the author. Ghent University Department of Speech, Language and Hearing Sciences De Pintelaan 185, 2P1 9000 Ghent | Belgium Tel: +32 (0)9 332 94 26 | +32 (0)494 40 76 76 [email protected] | [email protected] “When people of similar frequencies come together, output is not a simple sum of individual work, but exponential. In science we term this phenomenon as resonance. Output at this stage is beyond any logical limit.” Adapted from Ravindra Shukla, A Maverick Heart: Between Love and Life, 2012 TABLE OF CONTENTS LIST OF PUBLICATIONS 7 LIST OF ABBREVIATIONS 8 SUMMARY 10 SAMENVATTING 12 PART 1: GENERAL INTRODUCTION 15 CHAPTER 1: Instrumental and perceptual assessment of the velopharyngeal 17 function and resonance CHAPTER 2: Research objectives 49 PART 2: PUBLICATIONS 53 CHAPTER 3: Effects of age and gender in normal-speaking children on the 55 Nasality Severity Index: an objective multiparametric approach to hypernasality CHAPTER 4: The Nasality Severity Index 2.0: Revision of an objective 69 multiparametric approach to hypernasality CHAPTER 5: Influence of gender and age on the Nasality Severity Index 2.0 in 91 Dutch-speaking Flemish children and adults CHAPTER 6: Short-term and long-term test-retest reliability of the Nasality 107 Severity Index 2.0 CHAPTER 7: The relationship between the Nasality Severity Index 2.0 and 125 perceptual judgments of hypernasality CHAPTER 8: Short-term effect of short, intensive speech therapy on 151 articulation and resonance in Ugandan patients with cleft (lip and) palate PART 3: GENERAL DISCUSSION 173 CHAPTER 9: General discussion and conclusion 175 DANKWOORD 191 5 LIST OF PUBLICATIONS This doctoral thesis is based on the articles published or submitted in the following international peer-reviewed journals: 1. Bettens, K., Wuyts, F.L., & Van Lierde, K. (2014) Instrumental assessment of velopharyngeal function and resonance: a review. Journal of Communication Disorders, 52, 170-183. IF: 1.449, Q1 2. Bettens, K., Wuyts, F.L., De Graef, C., Verhegge, L., & Van Lierde, K. (2013) Effects of age and gender in normal speaking children on the Nasality Severity Index: an objective multiparametric approach to hypernasality. Folia Phoniatrica et Logopaedica, 65, 185-192. IF: 0.550, Q4 3. Bettens, K., Van Lierde, K., Corthals, P., Luyten, A., & Wuyts, F.L. (2016) The Nasality Severity Index 2.0: revision of an objective multiparametric approach to hypernasality. The Cleft Palate-Craniofacial Journal, 53(3), e60-e70. IF: 1.203, Q3 4. Bettens, K., Wuyts, F.L., Jonckheere, L., Platbrood, S., & Van Lierde, K. (Revised) Influence of gender and age on the Nasality Severity Index 2.0 in Dutch-speaking Flemish children and adults. Logopedics Phonology Vocology. IF: 0.932, Q4 5. Bettens, K., Wuyts, F.L., Luyten, A., D’haeseleer, E., Meerschman, I., Van Crayelynghe, C., & Van Lierde, K. (2016) Short-term and long-term test-retest reliability of the Nasality Severity Index 2.0. Journal of Communication Disorders, 62, 1-11. IF: 1.449, Q1 6. Bettens, K., De Bodt, M., Maryn, Y., Luyten, A., Wuyts, F.L., & Van Lierde, K. (Revised) The relationship between the Nasality Severity Index 2.0 and perceptual judgments of hypernasality. Journal of Communication Disorders. IF: 1.449, Q1 7. Luyten, A., Bettens, K. (equal contribution), D’haeseleer, E., Hodges, A., Galiwango, G., Vermeersch, H., & Van Lierde, K. (2016) Short-term effect of short, intensive speech therapy on articulation and resonance in Ugandan patients with cleft (lip and) palate. Journal of Communication Disorders, 61, 71-82. IF: 1.449, Q1 7 LIST OF ABBREVIATIONS 95% CI 95% confidence interval 95% PI 95% prediction interval ANA audible nasal airflow ANCOVA analysis of covariance ANOVA analysis of variance Arms root-mean-square amplitude BCLP bilateral cleft lip and palate CAPS-A Cleft Audit Protocol for Speech – Augmented CLP cleft lip and palate CP cleft palate CP±L cleft palate with or without cleft lip CoRSU Comprehensive Rehabilitation Services in Uganda CPAP continuous positive airway pressure CT computed tomography DME direct magnitude estimation DSI Dysphonia Severity Index EAI equal appearing interval FFT Fast Fourier Transformation HFP high frequency power HONC index Horii’s Oral Nasal Coupling index ICC intraclass correlation coefficient IPA international phonetic alphabet IRB Institutional Review Board LFP low frequency power LTAS long-term average spectrum MDD minimal detectable difference MDT maximum duration time MRI magnetic resonance imaging n.a. not applicable NORAM Nasality Oral Ratio Meter NSI Nasality Severity Index PAT-3 Photo Articulation Test – third edition PTA pure threshold audiometry ROC receiver operating characteristic SD standard deviation of the mean SEM standard error of measurement SLP speech-language pathologist SNAP Simplified Nasometric Assessment Procedures 8 List of abbreviations SNAP-R Simplified Nasometric Assessment Procedures – Revised SNORS Super Nasal Oral Ratiometery System SNR signal-to-noise ratio SPSS Statistical Package for Social Sciences t.n.p. testing not possible TONAR The Oral Nasal Acoustic Ratio UCLP unilateral cleft lip and palate VAS visual analogue scale VIF variance inflation factor VLHR voice low tone to high tone ratio VPI velopharyngeal insufficiency VRPIc Voice Range Profile Index for Children 9 SUMMARY For decades, researchers have been searching for the most ideal assessment technique in order to diagnose resonance disorders and to decide on the most apposite treatment. Currently, the presence and degree of resonance disorders is determined by a combination of perceptual judgments and indirect assessment techniques. As speech perception is fundamentally perceptual in nature, perceptual assessments have been traditionally applied to evaluate speech disorders. However, several variables can influence listeners’ perception of resonance which may limit the reliability and validity of perceptual judgments. Consequently, numerous indirect assessment techniques were developed to complement and objectify perceptual assessments. Nevertheless, no indirect technique can yet closely reflect the capabilities of the human ear. A possible solution to sidestep the limitations of single indirect instrumental assessment techniques is the combination of different variables into a multiparametric index. Following this, Van Lierde et al. (2007) took a first step in creating an instrumental and multiparametric protocol to assess resonance disorders by constructing a ‘Nasality Severity Index’ (NSI). The initial aim of this doctoral thesis was to explore the application of this NSI as a new, multiparametric approach to determine hypernasality in daily clinical practice. To verify the possible influence of personal and environmental variables on the original NSI, the data of 74 Dutch-speaking Flemish children without resonance disorders (mean age (SD): boys 8.3y (2.0), girls 8.4y (2.2); range 4-12y) were analyzed. Based on these data, an influence of age and environmental variables was found, resulting in a large spread of NSI values, even in children without resonance disorders. Consequently, an adaptation of the original NSI with inclusion of new assessment techniques was aimed, in which the influence of these above-mentioned variables was taken into account. Therefore, additional acoustic techniques to determine hypernasality were explored and included in a statistical analysis to derive a second version of the NSI, namely the Nasality Severity Index version 2.0 (NSI 2.0). Based on the optimal statistical discrimination of 35 children with perceived hypernasality and a control group of 50 children without resonance disorders, a weighted linear combination of three acoustic parameters was established. More specifically, the nasalance value of the vowel /u/ and an oral text passage obtained by the Nasometer and the voice low tone to high tone ratio (VLHR) of a sustained vowel /i/ with a cutoff frequency of 4.47*F0Hz were included. The formula of the adapted NSI yields NSI 2.0 = 13.20 – (0.0824 x nasalance /u/ (%)) – (0.260 x nasalance oral text (%)) – (0.242 x VLHR /i/ 4.47*F0Hz (dB)). With a sensitivity of 92% and a specificity of 100%, using a cutoff score of zero, the NSI 2.0 distinctively discriminates children with hypernasality from children with normal resonance, in which a score below zero indicates the presence of hypernasality. 10 Summary To implement this new index
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