Speech Sound Disorders in Arabic School aged Children with Adenoid Hypertrophy

Abstract

Background

Adenoid hypertrophy alters the posture of the oro-facial structures by obstructing the upper airways and restricting nasal breathing. These postural changes may eventually have an impact on facial skeletal development and dental occlusion. The postural adjustments may negatively impact a child’s life by affecting a number of speech-production factors.

Objective

This study aimed to detect the speech sound disorders in school aged Egyptian children with adenoid hypertrophy and if they were related to structure changes in the airway that caused by adenoid hypertrophy.

Methodology

300 school-aged Egyptian children aged from (5–15) years old with speech sound disorders (SSD). They were divided into 2 groups; Group 1 consisted of 150 children with speech (SSD) and adenoid hypertrophy, and Group 2 consisted of 150 children complained from (SSD) without adenoid hypertrophy. All children were evaluated by protocol of language assessment and articulation test used in Assiut University Hospital.

Results

Speech sound disorders (SSD) mainly the omission and distortion are more frequent in (group 2) while, the substitution errors are more prominent in (group 1). The interdental sigmatism was the most frequent speech sound disorder in (group 1) especially those with adenoid hypertrophy occupying more than 50% of the airway, whereas, devoicing, gliding and back to front are more frequent in (group 2).

Conclusion

Adenoid hypertrophy can affects only the /s/ sound production which needs precise placements of the articulators especially the tongue, and seems to be vulnerable due to the structural alteration of the oral cavity caused by adenoid hypertrophy.

Introduction

Children with adenoid hypertrophy frequently have a variety of symptoms include mouth breathing, nasal discharge, snoring, and sleep apnea. It also may cause a physical change that may impact speech [1, 2] because it obstructs the upper airway, which may disrupt the development of the teeth and the craniofacial region [3]. The large adenoids obstruct nasal breathing, resulting in mouth breathing and the typical “adenoid face” [4]. The adenoid face has the following characteristics when compared to healthy controls: an ineffective upper lip, a retropositioned hyoid bone, a narrow upper dental arch, anterior open bite, retropositioned mandibular incisors, increased anterior face height, a narrow or “V”-shaped maxillary arch, increased mandibular plane angle, a posteriorly rotated mandible and the tongue is positioned downward in the mouth [3].

A blockage of the upper airways may be the source of the medical condition known as mouth breathing. A common definition of long term mouth breathing is that the breathing pattern has persisted for at least six months [5]. Some of the implications of mouth breathing include changes in speech, nutrition, body posture, sleep quality, and academic performance [6, 7]. Mouth breathers may experience changes in their speech as a result of changes in their orofacial habits, as well as changes in the muscular tone, mobility and posture of the tongue, lips, cheeks, teeth and jaw [8–10]. Mouth breathers may have different activity of speech muscles because their tongues rest in a lower part of the mouth. In addition to anatomical and osseous problems, oral respiratory mode is also linked to the development of malocclusion, which in turn can cause speech changes such the speech lisp [11, 12].

Flaccid facial muscles, an improper tongue position, malocclusion-related problems with the oral cavity, and/or problems with facial growth and development can all disrupt speech [13, 14].

The most often reported speech abnormalities in mouth breathers include frontal (FL) and lateral (LL) lisps, imprecision in bilabial (/p/, /b/, /m/) and fricative (/f/, /v/,/s/,/z/,/ ³/, /ʃ/) phonemes in Portuguese, and anterior tongue position during lingual dental phoneme production [15–17]. This study aimed to detect the speech sound disorders in school aged Egyptian children with adenoid hypertrophy and if they were related to structure changes in the airway that caused by adenoid hypertrophy.

Methods

The study included 300 school-aged monolingual Arabic speaking children aged (5–15) years old. Subjects were divided into 2 groups according to the presence or absence of adenoid hypertrophy where( Group 1) included 150 children complaining from speech sound disorders and symptoms and signs of adenoid hypertrophy group (1) also divided in to two subgroups (A) (adenoid size less than 50%)and (B) (adenoid size more than 50%).

, and (Group 2) included 150 children suffering from speech sound disorders without any symptoms and signs of adenoid hypertrophy. Patients with neurological disorders, orofacial structural abnormalities such as cleft lip/palate, tongue tie, children with delayed language development, mental retardation, hearing impairment and past history of any speech therapy are all excluded from the study. All children were recruited from the outpatient clinic of the Phoniatric Unit, Assiut University Hospital. All patients were subjected to the following protocol of assessment:

A- Parents’ Interview

Complaint and analysis of symptoms, Personal history (age, birth order). Family history, Developmental history (prenatal, neonatal and postnatal), Milestones of development and Illness of early childhood.

B- Patient Examination

General examination and neurological examination to exclude any neuromuscular abnormalities.

C-Visual assessment of the vocal tract: Lips: To exclude clefts, scars, or philtrum deviation, Bite: To detect the occlusion status according to Angle’s classification [18], Alveolus: To exclude clefts, scars, or fistula, Tongue: To check the mobility and exclude any morphological/neurological abnormalities as atrophy or fasciculation, Hard palate: to exclude clefts, scars, or fistula, Soft palate: Intact/cleft, Length: Normal/shortened, Mobility: Active/Impaired mobility/palatal paralysis, Uvula: Intact/Bifid/cleft.

D- Ear and nose Examination

to exclude any cases with associated disorders.

E-Psychometric Evaluation

Cognitive age (mental age) evaluation using Stanford Binet intelligence scale [19].

F-Audiological evaluation

Pure tone audiometry, tympanometry.

G- Language evaluation

Using the Arabic language test (to exclude cases of delayed language development) [20].

H- Arabic Articulation test

It examines (23) Egyptian phonemes. Each phoneme was examined in the initial, middle and final positions. Then for each child we calculate the number of phonemes that were uttered wrong (omission, distortion and substitution). Substitution errors were analyzed to detect the most frequent affected phonemes, the most frequent type of errors and in what position in the word [21].

I- Diagnosis of Adenoid Enlargement

was done by.

1. History of snoring, mouth breathing, sleep apnea with occasional daytime sleepiness and inattention.

2. Clinical nasal examination to detect the presence of chronic rhinitis or chronic nasal obstruction.

3. Instrumental evaluation: Lateral radiograph of the nasopharynx where the adenoid size was estimated by measuring the distance between the outmost point of the adenoid shadow and the line along the spheno/bsioocciput [22].

4. Flexible nasoendoscopy (Storz Tele pack X LED-TP100): To detect the presence of a hypertrophied adenoid lymphoid tissue, its size, and the degree of palatal mobility. The patient was seated or held by the mother/caregiver in an upright position on a chair in front of the examiner with gentle immobilization of the head of the child, the most patent nasal side was determined and topical anesthesia was applied for an easy passage of the endoscope. The endoscope was guided up along the nasal floor then the middle meatus between the middle and inferior turbinate. The entire procedure was followed and videotaped on the monitor. Subjects were further classified into 2 groups according to the adenoid size; (Group A) contained patients with hypertrophied adenoid occupying less than 50% of the airway during maximal inspiration, and ( Group B) contained patients with adenoid occupying more than 50% of the airway.

Statistical Analysis

Date entry and data analysis were done using SPSS version 24(Statistical Package for Social Science). Data were presented as number, percentage, mean, standard deviation. Chi-square test was used to compare between qualitative variables. Independent sample t-test was used to compare quantitative variables between groups. P-value considered statistically significant when P < 0.05.

Results

Demographagic data of the Study Subjects

No discrepancy between both groups as regards the age as the mean age of (group 1) is 8.22 ± 2.90, and that of (group 2) is 8.99 ± 3.34. Similarly, no significant differences were found between the groups regarding gender as the (group 1) included 70 (46.7%) females, and 80(53.3%) males, and (group 2) included 54(36.0%) females and 96(64.0%) males. Demographic data of the study groups is shown in Table (1).

Table 1.

Demographic data of the study groups

Item	Group 1 “n = 150”	Group 2 “n = 150”	P-value
1-Age ”yrs.” Mean ± SD (min-max) < 7yrs. 7-10yrs. 10-12yrs. > 12yrs. 2-Sex: Female Male 3-Adenoid in subject group: Adenoid > 50% < 50%	8.22 ± 2.90 (5.0–15.0) 82(54.7%) 36(24.0%) 16(10.7%) 16(10.7%) 70(46.7%) 80(53.3%) 92(63.9%) 52(36.1%)	8.99 ± 3.34 (5.0–19.0) 68(45.3%) 44(29.3%) 14(9.3%) 24(16.0%) 54(36.0%) 96(64.0%)	P = 0.129n.s P = 0.123n.s

Data expressed as number and percentage, mean ± SD using Chi-Square test in categorical data, using T-test in numeric data in comparison between group 1, and group 2. ^n.s p-value non significant.

Speech Sound Disorders in Study Groups

Table (2) shows speech sound disorders in study groups. There was moderate significant difference (P < 0.001) between group 1, and 2 as regards the omission, also there was highly significant difference (P < 0.000) between the two groups regarding the distortion. However, no significant differences are noticed (P > 0.05) between them as regards the substitution.

Table 2.

Speech sound disorders in study groups

Item	Group 1 “n = 150”	Group 2 “n = 150”	P-value
-Omission -Distortion -Substitution:	56(37.33%) 34(22.67%) 150(100%)	88(58.67%) 66(44.0%) 148(98.67%)	P < 0.002** P < 0.000*** P = 0.276n.s

Data expressed as number and percentage using T-test in numeric data in comparison between subjects & control groups. ** p-value moderate significant *** p-value highly significant.

Substitutions Errors in Study Groups

Table (3) shows substitutions errors in study group. There was highly significant difference (P < 0.000) between both groups regarding devoicing, and moderate significant difference (P < 0.001) between the two groups with each of the gliding, back to front and interdental sigmatism.

Table 3.

Substitutions errors in the study groups

Item	Group 1 “n = 150”	Group 2 “n = 150”	P-value
1-Devoicing 2-Gliding 3-Back to front 4-Interdental sigmatism 5-Lateral Sigmatism 6-Pharyngeal Sigmatism	29(38.7%) 52(34.7%) 16(10.7%) 80(53.3%) 18(12.0%) 4(2.7%)	58(77.3%) 94(62.7%) 50(33.3%) 42(28.0%) 8(5.3%) 12(8.0%)	P < 0.000*** P < 0.001** P < 0.001** P < 0.001** P = 0.123n.s P = 0.138n.s

Data expressed as number and percentage using Chi-test in numeric data in comparison between subjects & control groups. ** p-value moderate significant *** p-value highly significant ^n.s p-value non significant.

Relation between SSD and Adenoid size in Group 1

There was no significant difference between SSD and the adenoid size as regard the (omission, distortion and substitution). Nevertheless, substitution errors are more frequent in group B (adenoid size more than 50%), No significant differences (P > 0.05) are observed between substitution errors and adenoid size. Nevertheless, it is noticed that interdental sigmatism is more frequent in patients with adenoid size more than 50% of the airway, Table (4).

Table 4.

Relation between SSD and adenoid size in group 1

Item	Group A (Adenoid size < 50%)	Group B (Adenoid size > 50%)	P-value
-Omission -Distortion - Substitution	38(63.3%) 22(36.7%) 52(100%)	16(61.5%) 10(38.5%) 92(100%)	P = 0.587n.s
1-Devoicing 4-Gliding 5-Back to front 6-Interdental sigmatism 2-Lateral Sigmatism 3-Pharyngeal Sigmatism	16(30.8%) 14(26.9%) 6(11.5%) 26(50.0%) 10(19.2%) 4(7.7%)	38(41.3%) 34(37.0%) 10(10.9%) 52(56.5%) 8(8.7%) --	P = 0.265n.s P = 0.274n.s P = 0.608n.s P = 0.176n.s P = 0.176n.s P = 0.127n.s

Data expressed as number and percentage Using Chi-test in numeric data. To comparison between subjects & control groups. ^n.s p-value non significant.

Relation between Types of Substitution Errors and age Groups in Group 1

Table (5) shows relation between Phonological errors and age groups in study group. There was no significant different (P > 0.05) between age groups with different types of substitution errors.

Table 5.

Relation between types of substitution errors and age groups in group 1

Item	Age groups				P-value
	< 7yrs.	7-10yrs.	10-12yrs.	> 12yrs.
1-Devoicing 2-Lateral Sigmatism 3-Pharyngeal Sigmatism 4-Rotacism 5-Back to front 6-Interdental stigmatism	30(36.6%) 8(9.8%) 4(4.9%) 34(41.5%) 14(17.1%) 40(48.8%)	12(33.3%) 2(5.8%) -- 12(33.3%) 2(5.6%) 22(61.1%)	12(75.0%) 2(12.5%) -- 6(37.5%) -- 8(50.0%)	4(25.0%) 6(37.5%) -- -- -- 10(62.5%)	P = 0.146n.s P = 0.120n.s P=-- P = 0.163n.s P = 0.244n.s P = 0.781n.s

Data expressed as number and percentage Using Chi-test in numeric data. To comparison between subjects & control groups.^n.sp-value non significant.

Relation between Types of Substitution Errors and sex in Group 1

Table (6) shows relation between substitution errors and sex in group 1. There was moderate significant difference (P < 0.001) between gender with interdental stigmatism. There was no significant different (P > 0.05) with other types of substitution errors.

Table 6.

Relation between substitution errors and sex in group 1

Item	Female “n = 70”	Male “n = 80”	P-value
1-Devocing 2-Lateral Sigmatism 3-Pharyngeal Sigmatism 4-Rotacism 5-Back to front 6-Interdental sigmatism	28(40.0%) 8(11.4%) 4(5.7%) 28(40.0%) 6(8.6%) 26(37.1%)	30(37.5%) 10(12.5%) 0 24(30.0%) 10(12.5%) 54(67.5%)	P = 0.586n.s P = 0.214n.s P = 0.214n.s P = 0.253n.s P = 0.434n.s P < 0.008**

Data expressed as number and percentage Using Chi-test in numeric data. To comparison between subjects & control groups.^n.sp-value non significant.

Discussion

The most prevalent cause of upper airway obstruction in children is adenoid hypertrophy. It has a negative impact on more than one component of the child’s development. Aside from causing sleep disruption, snoring, and mouth breathing, it also has an impact on dental and maxillofacial growth, which can impede speech and articulation development. Prolonged upper airway obstruction and mouth breathing can result in the typical adenoid face, complete with specific stigmata such as a narrow upper dental arch, retropositioned mandibular incisors, increased anterior face height, a narrow or “V”-shaped maxillary arch, increased mandibular plane angle, and a posterior-rotated mandible (8).

In our study we found that omission and distortion were significantly more frequent in the children without adenoid hypertrophy than children with adenoid hypertrophy while substitution errors were more frequent in children with adenoid hypertrophy. This probably due to articulation errors of children with adenoid hypertrophy may be resulted from anatomical or functional defects of articulation organs rather than children’s phonological concept [8].

We also found that the most frequent substitution error in patients with adenoid hypertrophy was substitution of /s/ with /θ/ (interdental sigmatism). Which was more evident in children with hypertrophied adenoid lymphoid tissue occupying more than 50% of the airway. Because of the reduced nasopharyngeal space caused by adenoid hypertrophy and mouth breathing habits, the jaw and tongue are dropped to maximize the oral airway. This impacts craniofacial development and results in dental occlusion aberrations such as a significantly more open intermaxillary jaw relationship, retrognathic inclined mandible, lateral cross-bite, and narrower inter-canine width, all of which lead to improper articulation of the/s/sound [3].

In addition, 33% of children with sleep-disordered breathing had Class II or asymmetric malocclusion, according to a Finnish study. [14] An open bite can distort the /s/ sound generated by the tip of the tongue in the dento-alveolar area. Many people produce normal /s/ with a low tongue tip and the tongue blade at the place of greatest constriction, which is always in the region described. Sibilant /s/ sound distortion has been commonly documented in speakers with malocclusion, possibly because /s/ generation demands very accurate placement of the articulators. [17]

Salami et al.,. Found that 42.5% of patients with adenoid enlargement before surgery had abnormal /s/ sound production [16]. The resonance cavity anterior to the mid sagittal groove in the tongue has a significant role in the sound quality of the /s/ production [23]. Several studies have shown that maxillary growth as well as dental arch morphology is affected by adenoid hypertrophy [23].

Additionally, Hammarston et al. [24] examined the impact of adenotonsillar hypertrophy on children’s /s/ articulation and the impact of surgery. They discovered that before surgery, children’s /s/ articulation was affected both perceptually and acoustically, with less distinct /s/ production than controls. Following surgery, the perception of the /s/ articulation was normalized.

Substitution errors of devoicing, gliding and back to front are more frequent in children without adenoid hypertrophy as they are not related to anatomical alternation, but due to difficulties acquiring the underlying linguistic representations of speech sounds. One possible explanation is that children with phonological disorder are unable to derive the rules governing their language’s phonological system [25].

Our results showed that omission and distortion and substitution were more frequent in younger age group (less than 7 years). The sound substitution, omission and distortion may occur because an underlying difficulty with the organization of phonological rules and/or auditory perception and speech production [3, 4]. The use of simplification of the phonological rules, called phonological processes (PP), is maintained after the expected age of acquisition in children with SSD and this is more common in younger children [26].

Interestingly, interdental sigmatism was more in male than female which agreed with Hammarston et al., [24] who found that male children with adenoid hypertrophy had more affection of /s/ sound production than female children. This can be explained by that females are known to have an earlier maturation of motor skills in general and speech articulation in particular.

Conclusion

SSD (omission, distortion and substitution including devoicing, Gliding and back to front) occurs more frequent in the children without adenoid hypertrophy than children with adenoid hypertrophy, only substitution errors affecting the /s/ sound (interdental sigmatism lateral sigmitism) occur more in children with adenoid hypertrophy as /s/ sound production needs precise placements of the articulators especially the tongue, which seems to be vulnerable to the structural alteration of the oral cavity that adenoid hypertrophy causes.

Author Contributions

All authors contributed to the study conception and design. Material preparation, data collection and analysis were performed by Hanan A. Mohamed. The first draft of the manuscript was written by Hanan A. Mohamed and Reham A.Ibrahem. All authors commented on previous versions of the manuscript. All authors read and approved the final manuscript.

Funding

No financial support was received for this study.

Declarations

Ethics approval and consent to participate

Approval of the Ethics Committee of the Faculty of Medicine, Assiut University was obtained before initiating the study (IRB number 04-2023-300070).

Consent to Participate

Informed written consent to participate in this study was provided by parents /or legal guardians of all participants.

Competing Interests

The authors declare that they have no competing interests.