Phoniatric Protocol for assessment of nasality used in Sohag multidisplinary cleft clinic

 

El-Adawy A. A.N., Emam A.M., Hassan M.M., El Rabie M.A.,Mostafa E. M. and Gelaney A. E.A.

 

Phoniatrics unit, otolaryngeology department, Sohag University.

 

Abstract:

The aim of this study is to develop Sohag protocol for assessment of hypernasality in patients with velopharyngeal valve incompetence (VPI).

After revision of available protocols of assessment of nasality we choose 3 main protocols to develop our protocol which are protocol of Ain Shams Phoniatrics Unit (Kotby et al., 1997), Great Oromond Multidisplinary cleft clinic (sell et al., 1999) and Ann Kummer assessment ptotocol (Kummer, 2005).The developing protocol was presented and revised by the phoniatricans of Sohag university phoniastrics unit and the Surgeons of cleft palate team then it was applied on twenty four consecutive patients with previously repaired cleft palates and symptomatic velopharyngeal incompetence were selected by Sohag protocol of assessment of hypernasality from patients who came to Sohag multidisplinary cleft clinicand managed surgically by a single operation and singe surgeon.

The results of the operationwere statistically significant reflectingimprovement in patients after the operation.

Keywards

Hypernasalty, endoscopy, lateral videofluroscopy, protocol of assessment

 

Introduction

 

 

Velopharyngeal insufficiency (VPI) is defined as an incomplete closure of the velopharynx. VPI affects speech, language and voice. It affects speech causing Hypernasality, nasal air emissions, articulation errors (weak consonants and many compensatory mechanisms).

Also VPI affects the development of language causing delayed language development.

The affection of language, speech and voice requires good assessment protocol for choosing best management and best results.

There are many different protocols for assessment of nasality around the world like protocols Ain Shams Phoniatrics Unit, Great Ormont street hospital (GOSH) and Ann kummer protocols for assessment of nasality. These previous three protocols are commonly used in Egypt.

The purpose of this study is to discuss recent advances in evaluation of VPI in patients with developing a protocol for evaluation of nasality at sohag university hospital.

 

Material and method:                                                        

  • Search for available well-formed protocols for assessment of nasality like Ain Shams Phoniatrics Unit, Great Ormont street hospital, Ann kummer protocol andPittsburgh Weighted Speech Scale (PWSS)(McWilliams and Phillips 1979).
  • Review and discuss three main protocols (Ain Shams Phoniatrics Unit, Great Ormont street hospital and Ann kummer protocols) by phoniatrics team of Sohag university hospital.

The design of the protocol passed through these steps

  • It was established by one phoniatrican
  • Reviewed and revised by all phoniatricans of Sohag phoniatric unit (six phoniatricans).
  • It was presented, reviewed and revised by the cleft palate surgeons of Sohag multidisplinary cleft clinic.
  • To detect its sensitivity and specificity it was applied to a number of patients (24 patients) who were managed by a single operation and single surgeon.
  • Statistics: the results were analyzed using Wlicoxon Test of significance to detect patients' improvement. Also spearman correlation test was used to detect correlation betweendifferent items of assessment.

 

Results of the study:

After Reviewing all available protocols of assessment of nasality we decided to choose the main three suitable protocols that are aligned with our view and facilities in Sohag phoniatrics unit. All these protocols agree in the main items of its structure. They include patient and parent interview, orofacial examination, auditory perceptual assessment, nasoendoscopy and videofluroscopy. But they differ in some of their detailed assessment and the major investigation of assessment. For instance Great Ormont street hospital protocol depends mainly on lateral videofluroscopy for choosing the appropriate line of management while Ann kummer protocol depends mainly on nasoendoscopic examination (table 1).

 

 

Table (1): comparison between different protocols of assessment of nasality

 

Ain Shams protocol

GOSH protocol

Ann kummer protocol

Patient and

Parent interview

One evaluation sheet includes

data from parents and patient

with little concern about patient current concern, articulation, resonance and learning achievement

Two evaluation sheets according to age with little concern about impact of

cleft on articulation, resonance, psychological

and learning achievement

One evaluation sheet with

less concern about analysis

of feeding problem, previous therapy and learning achievement

Auditory

perceptual

assessment

Good assessment of speech,

Language and voice with little

Concern about consistency of hypernasality, articulatory

Errors. Also the relation of

Nasal air emission to sounds

Good assessment of

Speech and Language

little Concern about voice

analysis.

Good assessment of

Speech and Language

little Concern about voice

analysis.

Orofacial

examination

No difference

No difference

No difference

Endoscopy

Much concern on

nasoendoscopy to

take decision of

management

Less concern with on nasoendoscopy to

take decision of

management

Much concern with on nasoendoscopy to

take decision of

management

videofluroscopy

Less concern with on videofluroscopy to take

decision ofmanagement.

Depends on two views

that increase the risks of

exposure to irradiation

Much concern with on Lateral videofluroscopy

only to take decision

ofmanagement with

concern in details like site

of the genu.

Less concern with on videofluroscopy to take

decision ofmanagement.

Depends on two views

that increase the risks of

exposure to irradiation

Other investigations

Nasometry is the most

valuable and commonly used

Nasometry is the most

valuable and commonly

used

Nasometry is the most

valuable and commonly

used

 

 

The Results of reviewing the protocol was

  • There were frequent revisions of the protocol by the phoniatricans for some items in the patient interview like adding the effect of clefting on learning, adding the degree of velar convexity by endoscopy, choosing one view for videofluroscopic assessment instead of two to decrease the duration of exposure to irradiation and making a guide for the phoniatricans and the families about patient evaluation.
  • There were some modifications of our cleft surgeons like more concern on lateral videofluroscopic especially the site of the genu and presence or absence of adenoid and its level by endoscopy and videofluroscopy.
  • The results of application of the developing protocol on patientswith VPI was as the following (table 2,3,4,5)

The study was conducted on a series of 24 patients with VPI presented to the multidisciplinary cleft clinic at Sohag university hospital and underwent a single operation by a single surgeon 16 females and 8 males our mean age for operation is 10 years month.

Speech results:

There were statically significant improvement in the degree of hypernasality, nasal air emission and imprecision of consonants.But there were no significant change in compensatory articulatory mechanisms (table 2)

 

Table (2): Different variables of speech assessment before and 6 month after operation.Wilcoxon Signed Ranks Test*p<0.05 (two-tailed).(significant) and **p< 0.01 (highly significant)

Parameters

Pre-operative

6 months after the operation

 

(Mean/+SD)

(Mean/+SD)

P value

Degree of open nasality

(2.92+0.41)

(0.96+0.69)

0.000

Nasal air emission

(1.54+0.88)

(1.12+0.85)

0.015

Consonants imprecision

(0.77+0.38)

(0.66+0.48)

0.046

Facial grimace

(1.50+0.93)

(1.29+1.08)

0.010

Overall intelligibility

(2.66+0.76)

(1.08+0.88)

0.001

Endoscopic results:

There were statically significant improvement in the degree of palatal convexity, velar movement and overall closure. But there were no significant change in lateral Pharyngeal wall movement (table 3)

Table (3): Different variables of endoscopic assessment before and 6 month after operation. Wilcoxon Signed Ranks Test(two-tailed). *p<0.05 (significant) and **p< 0.01 (highly significant)

 

Parameters

Pre-operative

6 months after the operation

 

(Mean/+SD)

(Mean/+SD)

P value

Palatal convexity

0.73+0.46

1.55+0.34

0.003

Velar Movement

1.56+0.57

3.77+0.97

0.001

Lateral Pharyngeal wall movement

1.22+0.58

1.0+0.53

0.096

Overall closure

1.68+0.58

3.86+0.89

0.000

 

 

Lateral videofluroscopy:

There was statically significant improvement in the palatal length, velar thickness, velar height and velar movement (table 4)

Table (4):Different variables of lateral videofluroscopic assessment before and 6 month after operation. Wilcoxon Signed Ranks Test(two-tailed). *p<0.05 (significant) and **p< 0.01 (highly significant)

Parameters

Pre-operative

6 months after the operation

 

(Mean/+SD)

(Mean/+SD)

P value

VelarLength

0.45+0.68

1.78+0.41

0.000

Velar Thickness

0.35+0.45

1.68+0.47

0.000

Velar Movement

1.63+0.74

3.7368+0.99

0.008

Velar Height

1.34 + 0.68

3.0000 + 0.81

0.005

 

Correlation between different variables:

There was strong positive correlation between different variables

Table (5): correlation between different variables of assessment protocol. Spearman correlation test *p<0.05 (significant) and **p< 0.01 (highly significant)

 

P Value

APA and velar movement by endoscope

0.001

APA and Velar height by lateral videofluroscopy

0.000

Total closure by endoscope and velar movement by

lateral videofluroscopy

0.000

 

After revision by phoniatricans, cleft Surgeons and application on the patients with VPI the final protocol of assessment of nasality at Sohag university Phoniatric clinic was developed (Appendix 1). Also a guide for the patients and phoniatricans was written (Appendix 2).

 

 

Discussion

 

To develop our protocol of assessment we choose three main protocolsAin Shams Phoniatrics Unit, Great Ormont street hospital and Ann kummer protocols. As these protocols are the most suitable for application with our facilities, they have nearly the same structure (speech assessment, videoradiography, andnasopharyngoscopy). (Golding-Kushner et al., 1990; Birch et al., 1994), and they are the most commonly protocols used in Egypt.

The developed protocol revised a number of phoniatricians with experiences ranging from 7 years up to 25 years and a number of cleft surgeons with experiences ranging from 15 years to 25 years. This adds more sensitivity and specificity with application on the patients after frequent revisions.

Comparing Sohag Phoniatric unit protocol of assessment withprotocol of Ain Shams

 

 

 

Phoniatrics Unit (Kotby et al, 1997)for assessment of nasality, Sohag

 

 

Multidisplinary cleft clinic that have the following advantages:

  • During history talking it has some defects like patient concern as the patient may have hypernasality but he is complaining about cosmoses. Mother and strangers understanding of the patient's speech also gives indicator about the intelligibility of the patient's speech and the size of the problem. Also the psychological effect of nasality on the patient and the family.
  • Auditory perceptual assessment ofprotocol of Ain Shams Phoniatrics Unit was defective in the consistency of hypernasality, the analysis of nasal air emission (consistency, relation to the sound whether accompanying or replacing) and facial grimace analysis (its degree and consistency).
  • By videofluroscopy
  • Early we used 2 views for every patient and we were not limited with time. Now we used the lateral view only as the endoscope will give us data for most of other views. Now we are limited by 30 seconds for examination.
  • By lateral view we can detect the site of the genu whether anterior or posterior and this helps to detect the type of operation.
  • Position of levators and levator eminanace and size of the defect.

Comparing the protocol of assessment of nasality of Sohag phoniatric unit with that of Ann Kummer, Sohag phoniatric protocol has some advantages like choosing the lateral view videofluroscopy only to decrease time of exposure to irradiation also the lateral view is the most informative of all videofluroscopic views and we add more data like the site of the levators. Also with history taking we added the effect of clefting on learning.

 

Comparing the protocol of assessment of nasality of Sohag phoniatric unit with that of Great Ormont street hospital protocol, Sohag phoniatric protocol has some advantages in orofacial facial examination and more detailed nasoendoscopic examination.

Applying the protocol of assessment of nasality of Sohag phoniatric unit on a the patients of Sohag multidisplinary cleft clinic leads to improvement in the results after management of patients and this was proved by the surgical intervention for patients that showed improvement of hypernasality in about 80% of cases after 6 months of the operation with decrease in mean level of hypernasality this may be due to good evaluation of the velopharyngeal gap, velar length by lateral videofluroscopy. This Level was nearly the same 81% like Sommerlad (2002) who used Great Ormont street hospital protocol for management patients with palatal rerepair. In this study there were no significant change in compensatory articulatory mechanisms and this is similar to Kummer (2005). She reported that compensatory and placement errors are corrected by speech therapy once the surgical correction of the structure abnormalities has been done.

Applying Sohag protocol all patients who visits Sohag multidisplinary cleft clinic help us to choose the ideal line of management some patients were managed through speech therapy, others treated surgically.

Sohag protocol of assessment of nasality is effective in preoperative assessment for detecting a suitable line of management. That was proved by the statistically significant improvement of patient's speech after surgery.

 

   References

 

  1. Birch M., Sommerlad B.C. and Bhatt A. (1994): Image analysis of lateral velopharyngeal closure in repaired cleft palates and normal palates. Br J Plast Surg.; 47:400–405.

 

  1. Golding-Kushner K.J., Argamaso R.V. and Cotton R.T. (1990): Standardization for the reporting of nasopharyngoscopy and multiview videofluoroscopy: a report from an International Working Group. Cleft Palate Journal, 27, 337–347.

 

  1. Kotby M.N., Abdel Haleem E.K., Hegazi M., Safe E. and Zaki M. (1997): Aspects of assessment and management of velopharyngeal dysfunction in developing countries. Folia Phoniatrica et Logopaedica, 49: 139.

 

  1. Kummer A.W. (2005): Cleft palate and craniofatial anomalies: The effects on speech and resonance. Cincinnata, Ohio: WB Saunders, 401-424.
  2. McWilliams, B.J. and Phillips, B.J. (1979): Velopharyngeal Incompetence: Audio Seminars in Speech Pathology. Philadelphia: W. B. Saunders, Inc.

 

  1. Sell D., Harding A. and Grunwell P. (1999):SP.ASS’98. An assessment for speech disorders associated with cleft palate and/or velopharyngeal dysfunction (revised). International Journal of Language and Communication Disorders, 34, 17–33.
  2. Sommerlad, B.C., Mehendale, F.V., Birch, M.J., Sell, D., Hattee, C. and Harland, K. (2002): Palate re-repair revisited. Cleft Palate Craniofac J.39:295–307.

 

 

 

الملخص العربي

 

هناك بروتكولات عديده لتقببم الخنف عند الاطفال المصابين بشق سقف الحلق مثل برتوكول جامعة عين شمس وان كومر برتوكول وبرتوكول مستشفى جريت اورموند. هذه البرتكولات جيده ولكن من وجهة نظر اعضاء وحدة التخاطب لم تكن كافيه او مناسبه لتقييم المرضى المترددين على عيادة التخاطب بجامعة سوهاج لذلك تقرر تصميم برتوكول جديد خاص بوحدة تخاطب سوهاج وتم عمل خطوات عديده لعمل هذا البرتوكول

  • تم عمل مراجعه لكل البرتكولات المتخصصه بتقييم الخنف .
  • تم اختيار ثلاث بروتوكولات لتكون نواه للبرتكول الجديد وهيمثل برتوكول جامعة عين شمس وان كومر برتوكول وبرتوكول مستشفى جريت اورموند,
  • تم عرض البرتوكول على اعضاء وحدة الخاطب وتعديله اكثر من مره
  • تم عرض البرتوكول على جراحى سقف الحلق وتعديله اكثر من مره
  • تم اختبار البروتوكول على المرضي عن طريق استخدامه لتقييم المرضى قبل تدخل جراحى واحد عن طريق جراح واحد

بعد ذلك تم دراسه نتائج تطبيق البروتوكول الجديد والتى اثبتت كفاءة هذا البروتكول فى تقييم المرضى لاختيار الطريقه المثلى للعلاج

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Appendix (1)

 

Basic Phoniatrics Evaluation (>3 years)

 

History.

 

  • Personal data :

 

Name                                                 Age                     Sex                         Order of birth

Residance                                         Occupation                                           Date            

Education                                                                      Consanguinity                      

Father job &education                                                   Mother job & education              

Similar conditions                                                        Telephone number

 

  • Diagnosis :

……………………………………………………………………………………………………….

 

  • Complaint :

..……………………………………………………………………………………

 

Onset

Course

Duration

Current concern

Concern about: Growth, Feeding, Language, Speech, Cosmetic, Others      

 

  • Prenatal history :

 

Bleeding                                     Fever                                 Drugs

Hypertension                               Toxemia                            Anemia

Age of the mother                       others                                    

 

  • Perinatal and neonatal history :

 

Type of labour                         Term                                     Cry

Weight of the baby                  Cyanosis                               Jaundice

Resustation

        

  • Milestones :

Sitting                       Walking               Teething               Tiolet training         self feeding                          

Self dressing            1st word                                           1st sentence

 

  • Present History :

 

1- Analysis of the complaint

 

…………………………………………………………………………………

2- Language

 

a- Method of communications: Gesture, Single words, Short sentences, Long sentences

b- Maternal impression about intelligance?

 

3- Articulation

 

- Sounds produced in vocal play?                       - What consonants produced now?

- Mother understanding of speech?                     - Strangers understanding of speech?

- Particular sounds that are affected?

 

4- Feeding and Oral motor functions

 

- Method of feeding?

- Chewing, Suckling and swallowing difficulty?

- Chocking (Frequency- Type of food)?

- Regurge:                 1- (Unilateral or Bilateral)?

                                 2- Frequency ?                                 3- Type of food

- Drooling?               (Mild- Moderate- Severe- Profuse)

- Chest infections?

 

5- Hearing

 

- Subjective impression about hearing?                           - Infections?

- Surgery?                                                                          - Hearing tests?

 

6- Airway

 

- Snoring?                                                           - Stridor?

7- Learning in preschool and school age             Grade?............     (Good       - Fair     - poor)

8- Psychological Problems?

 

- Subjective impression about sociality?                                       b- Other problems?

  

9- Neurological problems?

 

10- History of speech and language therapy

 

- Site                                      - Number/ week

- Duration                               - Effect                                             - Regular or not

11- Medical History

 

- Congenital anomalies?                   - Other medical problems?

- Vision?                                          - Growth chart?

12- Surgical History

 

Operation

Type

Age

Place

Effect on

Speech

Effect on

Regurge

Lip

 

 

 

 

 

 

Palate

 

 

 

 

 

 

Adenotonsillectomy

 

 

 

 

 

Others

 

 

 

 

 

Examination.

 

  • General examination

General look:                                                              Vital signs:

 

  • Auditory perceptual assessment :
  • Language Evaluation :

1- Patient response to examiner:                             2- Eye contact:

3- Ability to imitate:                                                  4- Passive vocublary:

5- Active vocublary:

           Single words (number):                         Length of sentence:

           Semantics:                                             Syntax:                                 Phonology:

6- Attention:

 

  • Speech evaluation :

1- Resonance

1- Hypernasality    

     Degree:     0----1----2----3.                     Consistency: Consistent\ inconsistent

2-Hyponasality

     Degree:         0----1----2.                           Consistency: Consistent\ inconsistent

3-Mixed nasality

4-Cul de sac

 

 

2- Consonants & Arabic articulation test

 

 

b

m

w

f

θ

ð

θ

t

d

ş

s

z

Siwi

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Smwm

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Sfwf

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

n

L

ʃ

ʒ

r

k

g

q

x

 

ς

ħ

H

?

Siwi

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Smwm

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Sfwf

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

3- Nasal Emission

- Degree:                       0----1----2----3.                               - Consistency: Consistent\ inconsistent.

- Relation to consonant: accompanying\Replacing.             - Sounds with emission

 

4- Nasal Turbulance

- Degree:                       0----1----2.                                     - Consistency:Consistent\ inconsistent.

- Relation to consonant: Accompanying\Replacing.           - Sounds with turbulence

                          

5- Compensatory articulator mechanisms

- Glottal articulation:   0     1     2     3     4.               - Pharyngel alarticulation:   0     1     2     3     4

- Facial grimace:                          - Degree: 0----1----2----3.     - Consistency: Consistent\ inconsistent.

 

6- Utterance Length                                 Normal\Short

 

7- Unintelligibility of speech                      0       1       2         3       4

 

8- Simple evaluation Procedures

1-Mirror test (Czermzk's test):   /a/                     /i/                       /s/                     /f/

2-Feeling the sides of the nose   +ve                  -ve

3-Guetzman's test:                       +ve                 -ve

  • Voice evaluation :

- Dysphonia grade:                                             0   1   2   3   4

- Character:

     strain                 0   1   2   3   4                       leaky                         0   1   2   3   4

     breathy             0 1   2   3   4                     irregular (rough)       0 1   2   3   4

- Pitch:                 (habitual-decrease-increase-diplophonia)

- Loudness:           (habitual - soft - loud - fluctuating)

- Glottal attack:     (habitual - soft   - hard)

 

  • Orofacial examination :

 

1- Eye: intercanthal distance:(Normal- hypertelorism- hypotelorism).   Palpepral fissure:(normal -narrow).

2- Nose:  

       - Nasal bridge

       - Septum (Normal or deviated     Rt…….Lt)                           - Nose Patency

 

3- Ears:  

- External anatomy:     Shape                   Site                     -Tympanic membrane:

 

4- Facial bones and profile:

5- Lips:

       - Intact                     - cleft: Rt.                 Lt                               - Scar: Rt                         Lt

       - Bilabial closure:                                                                       - Lip pits

       - Lip mobility: Symmetric / Asymmetric                       Normal / reduced

6- Teething:

a- Dentations:missing-supernumory-fused-crowding-malformed-overerupture-mixed teeth-deciduous teeth

b- Occlusion:     I           -     II         -         III

c- Bite:         cross bite                 open bite                 over bite

( none             anterior           bil. Post.     Rt.post.     Lt. post.)

7- Hard Palate:

       - Alveolar Bridge:      

       - Mucosa: color                     papilla and rugae            

       - Cleft / Fistula:                                 - Scar:

       - High arched palate:                      - Palpation: Posterior palatal spine               Fistula

8- Velum and Uvula:

     a- Basic morphology

  • Cleft:                                                           - Scar:
  • Zona pellucida (Bluish line):                     - Inverted V:
  • Symmetry:

           -Uvula:   (normal     Hypo plastic       bifid     distorted     absent)

       b- Velar Length   (Adequate -Fair - Inadequate)

       c- Mobility: Upward direction (good- fair- poor- none).   Backward direction (good- fair- poor- none).

       d- Gag reflex:

 

9- Tonsils:                  0               1                 2             3               4

10- Pharynx:

   - Depth:                                           - Mobility: lateral                               posterior

   - Previous operation

11- Tongue:

   - Size:                                                   - Scar:                               - Mobility:

   - Ankyloglossia (Tongue tie):             - Cleft tongue:                     - Nodular tongue:

Judie For nasality sheet

 

(Appendix 2a) Nasoendoscopy

 

The success of the nasopharyngeoscopy procedure depends greatly on the individuals' cooperation.

Done preoperatively routinely to detect congenital anomalies even in young infants. Done 6 month postoperatively.

  • Inform the patient and the family about the procedure and get consent before examination.
  • Perceptual evaluation before examination.
  • Follow infection control instruction.
  • The patient blows his nose to discharge excess secretions.
  • Determine the nostril side for examination (The non cleft side for those with cleft if not the widest side by orofacial examination).
  • Apply Topical anesthesia and decongestant for 5 minuetes.
  • Explain the procedure again.
  • The child repeats standard phrases and sentences before examination.

 

Position of the patients:

The patient should be seated in a chair in front of the examiner. Ideally the patient should watch the procedure at the monitor. For a young child, it can be helpful to have the child seated on the parent's lap.

 

Passing the scope:

  1. The scope pass through the middle nasal meatus.
  2. Avoid contact with nasal septum that is painful
  3. The scope pass vertically and when reaching the choana the end of the scope needs to be turned down.
  4. After good visualization of the velopharyngeal port ask patient to repeat the speech sample.

 

Speech Sample:

  • Vowels, fricatives, plosives.
  • Oral sentence, Nasal sentence, oral-nasal sentence.
  • Affected sounds (By articulation test) with high vowel /i/ and low vowel /e/.
  • Sentences with affected sounds.
  • Spontaneous speech sample.

 

Writing the results

(Appendix 2b) Lateral Videofluroscopy

 

Videofluroscopy is a teqnique for visualizing the structure and function of the velopharyngeal valve

 

Preparation of the patients

  • Describe the procedure and its benefits to the patient and family before the examination.
  • The child repeats standard phrases and sentences before examination.
  • The child wears special protective clothes before examination.
  • During the examination, it is important for the physician to speak calmly to the child and reassure the child about the procedure.

 

Procedure

  • The patient stands in the upright position.
  • The table is vertically positioned.
  • The patient stands between the table and the fluoroscopic screen.
  • Good view when the rami of both mandibles are superimposed in the view.
  • Examination takes from 20 sec up to 30 sec.

 

Stimulus

  • Affected sounds (By articulation test) with high vowel /i/ and low vowel /e/.
  • Sentences with affected sounds.
  • Oral sentences
  • Nasal sentences
  • Combined oral- nasal sentences
  • Connected speech (counting from 1-10).