Ann Otol Rhinol Laryngol91: 1982.

VOCAL QUALITY, ARTICULATION AND AUDIOLOGICAL

CHARACTERISTICS OF CHILDREN AND YOUNG ADULTS
WITH DIAGNOSED ALLERGIES

BARBARA M. BAKER, PhD

LOUISVILLE, KENTUCKY

CLAUDE D. BAKER, PhD HA THANH LE, MD

NEW ALBANY, INDIANA ELIZABETHTOWN, KENTUCKY

This study details vocal quality, articulation errors, and hearing disorders in 80 children and young adults with diagnosed allergies.
Results indicated that almost 50% had abnormalities in vocal quality and/or articulation and 13% had reduced auditory acuity. Vocal
quality disorders showed a significant relationship to bronchial asthma in association with other allergic reactions. All subjects with
diminished hearing had allergic rhinitis either singly or in combination with another disorder. Findings suggest that bronchial asthma and
allergic rhinitis are related to the development of vocal quality disorders and that allergic rhinitis is associated with misarticulations and
diminished hearing, The presence of speech sound omissions in allergic rhinitis patients above age 8 may predict the presence or previous
history of fluctuating hearing loss.

INTRODUCTION apy. These specialists should recognize the multipli-

Allergic individuals are often characterized by
factors which may affect vocal, articulatory and
auditory mechanisms. These factors may include 1)
chronic cough, 2) throat clearing, 3) edema of the
mucous membranes of the nose, pharynx and vocal
cords, 4) enlarged adenoids, 5) otitis media, and 6)
a high incidence of vocal cord lesions, 1-5 These al-
lergic individuals may be more susceptible to devel-
oping disorders of vocal quality, articulation and
hearing. 3 Nasal allergies originating early in devel-
opment may contribute to poor nasal ventilation
and eventually produce underdevelopment of the
nasal sinuses. This condition in turn may produce
improper development of the maxilla and palatine
bones resulting in formation of a long narrow den-
tal arch and a high domed palate. Consequently,
many of the structural features related to proper
speech production may be affected, eg, malocclu-
sion of the dental arches.
The problems caused by allergies in children and
young adults are often compounded by the multi"
plicity of complaints involved. For example, the
chief presenting complaint of a young patient may
be bronchial asthma. However, the patient may
have previously experienced gastroenteritis, fol-
lowed by the development of rashes and urticaria. 3
The allergic attack may move into the upper respir-
atory tract and produce allergic rhinitis and serous
fluid in the middle ear, with concomitant dimin-
ished hearing. At any point in this process, the aller-
gic patient may be referred to a speech-language
pathologist or audiologist for evaluation and ther-
From the Program in Communicative Disorders, Department of Surgery, University of Louisville School of Medicine, and the Department of Biology,
Indiana University Southeast, New Albany.
REPRINTS - Barbara M, Baker, PhD, Departmen t of Surgery, University of Louisville School of Medicine, 530 South Jackson St., Louisville, KY 402.02,
277
city of factors involved in dealing with allergic pa-
tients.
Allergies have also been indicated in the develop-
ment of vocal quality and articulation disorders.
For example, Senturia and Wilson 2 found that there
was frequently a history of allergic rhinitis in chil-
dren with vocal quality disorders and Szanton 6 sug-
gests that allergic hearing loss may affect the quali-
ty of speech development and production.
Although the relationship of allergies to vocal
quality disorders, voice deviation and hearing loss
has been reported repeatedly, few, if any, studies
have detailed these hypothesized relationships, We
found instead many studies suggesting additional
work in these areas. For example, Szanton and
Szanton 78 state that studies of allergic disease may
establish etiologic conditions for many presently in-
explicable problems of speech and language devia-
tions. Yairi et al" note the need for more informa-
tion on the influence of allergies and other factors
on phonatory disorders, and Baynes 'O suggests that
the high incidence of chronic hoarseness in children
is an area for continued work. Therefore, the lack
of definitive information in this area warrants re-
search into the vocal quality and articulation char-
acteristics of allergy patients.
The purposes of this study are to describe the vo-
cal quality, articulation and hearing characteristics
of a group of children and young adults with di-
agnosed allergies, and to determine whether speci-
fic allergies resulted in specific vocal quality andlor

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278 BAKER ETAL
TABLE 1. VOCAL QUALITY, AUDITORY AND
FLUENCY DISORDERS AND ARTICULATORY ERRORS IN
PATIENTS WITH ALLERGIES IN LOUISVILLE (N = 80)
No. with
Experimental Parameter Disorder %
Vocal quality disorders 36 44.75
Articulatory errors 39 48.75
17 21.25
Vocal quality and articulatory errors
11 13.75
Auditory acuity disorders
Fl uency disorders o 0.00
misarticulation errors. The ultimate goal of re-
search of this type is to ascertain if specific articula-
tion and/or vocal quality errors may be used as di-
agnostic or predictive tools in the diagnosis and
treatment of allergy patients.
METHODS
Subiects. Eighty patients were selected randomly from those
being treated for allergic disorders at Norton-Children's Hospital,
Louisville. All medical intervention was withheld for approx-
imately 48 hours before assessment.
All patients were at least 8 years old (x = 12.1, range 8 to 23)
and possessed adequate oral structures and mobility as deter"
mined by a standard oral mechanism evaluation. Since adequate
articulation is normally achieved by age 8, the articulation errors
presented by this sample were assumed to be related to deviancy
rather than lack of articulation maturation."
Each patient had a complete history and physical examination,
routine and specific laboratory tests and allergy skin tests. The
history and physical examination were complete but emphasized
problems related to upper and lower respiratory systems, eyes,
ears, skin and gastrointestinal tract. Laboratory tests consisted of
a complete blood count, nasal smear, quantitative immunoglobu-
lins, chest x-ray films and, if necessary, x-ray films of sinuses and
finding sweat chloride value. If the patient was shown to be aller-
gic, skin tests for allergies to inhalants and food were done initi-
ally with scratch tests using 1 :20 weight/volume concentration ex-
tracts. Patients' allergies were diagnosed as being seasonal and/or
perennial allergic rhinitis, asthma, exercise-induced asthma,
serous otitis media, eczema, food allergy or other allergic disor-
ders, The use of symptomatic treatment and/or immunotherapy
depended on clinical manifestations, laboratory tests, allergy skin
tests, environmental control and avoidance,
Speech, Language and Hearing Assessment, Each patient was
administered the Fisher-Logemann Test of Articulation Compe-
tence, which was originally determined on subjects representing a
wide range of dialectic, socioeconomic and foreign language
backgrounds. In this test, the patients were instructed to name
stimulus pictures as the examiner pointed to them. Based on the
patients' responses, articulation errors were phonetically trans-
cribed on a standard form. The phonetic transcription was then
analyzed according to error type and phoneme classes.
Patients' speech samples, for vocal quality analysis, were tape-
recorded in a quiet room as they read aloud a selected passage.
Microphone-to-mouth distance was standardized at 30.5 cm. The
examiner then made a perceptual judgment of vocal quality ac-
cording to the parameters of frequency, intensity and resonance.
To determine speech fluency, each patient read a selected pas-
sage, then produced spontaneous speech elicited from picture
stimuli. A perceptual judgment was made by the examiner ac-
cording to methodology outlined by Johnson et aL"
In addition to speech-language analysis, each patient was given
pure tone air and bone conduction assessment on a Beltone por-
table audiometer, calibrated to the four standard frequencies of
1,000, 2,000, 4,000 and 6,000 Hz. l ]
After data collection, a nonparametric chi square analysis was
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TABLE 2. CHI SQUARE VALUES FOR ALLERGIES AND
VOCAL QUALITY DISORDERS
Vocal Quality Chi Square
Allergic Disorder Disorder Value
Bronchial asthma Mouth breathing 10.56'
Bronchial asthma & Hyponasality, voiced 10.56'
allergic dermatitis inhalations, difficult
breathing
Bronchial asthma, al- Breathiness, breathi- 39.491
ness & hyponasality
lergic dermatitis &
food allergy
Bronchial asthma, Hoarseness, low vocal 80.001
atopic dermatitis & intensity
allergic rhinitis
Allergic rhinitis & Low vocal intensity & 12481
urticaria breathiness
'Significant at p:50.01.
lSignificant at p:50.001.
employed to analyze the relation between vocal quality or misar-
ticulations and specific allergic disorders.
The observed frequencies of specific allergic disorders and
misarticulations were cast into a 2 x 2 contingency table to test the
null hypothesis of no difference between the two groups. The al-
ternative hypothesis was that a specific allergic disorder or dis-
orders were significantly related to certain types of misarticula-
tions or vocal quality disorders. The region of rejection consisted
of all x' values so large that the probability associated with their
occurrence was equal to or less than a = 0.05. If a significant dif-
ference was obtained, it was concluded that the specific allergic
disorder was found more frequently in conjunction with a specific
misarticuJation or vocal quality disorder.
RESULTS
In this population of 80 individuals, almost 50 %
of the subjects had vocal quality and/or articulatory
errors (Table 1); 21 % had both vocal quality and
articulatory errors, 11 patients had reduced audi-
tory acuity; no evidence was found of a fluency dis-
order (Table 1).
When the vocal quality disorders were broken
down to type of disorder, most patients exhibited
hoarseness (10 %), breathiness (7.5 %), hyponasali-
ty (6.25%) or low vocal intensity (3.75%), with
most of the remaining patients having a combina-
tion of these disorders.
The significant chi square values listed in Table 2
indicate that bronchial asthma, either singly or in
conjunction with other disorders, was related to
vocal quality disorders in 6 of 7 patients. Allergic
rhinitis, the only significant value not involving
bronchial asthma, was significantly related to low
vocal intensity accompanied by breathiness.
The articulation error analysis revealed a total of
136 errors distributed among 80 errors in blacks and
56 in whites. The errors ranged from 1-17 with a
mean number of 1.7 errors for all patients.
All 11 patients with hearing loss at the time of the
evaluation had allergic rhinitis either singly or in as-
sociation with another disorder (Table 3). The
range of the conductive type of hearing loss was 15
to 40 dB. This was found consistently across all sub-
jects in the low frequency range of 250 to 500 cps.
 ALLERGY & SPEECH & HEARING 279

TABLE 3. RELATIONSHIP OF HEARING LOSS TO spiratory infection or allergic rhinitis occurred fre-
ALLERGY DISORDER AND VOCAL QUALITY AND quently in children with vocal quality disorders.
MISARTICULA TlONS
These authors suggest that chronic allergic rhinosin-
Type of usitis may predispose a child to recurrent hoarseness
Subject Diarosed Misarticulations Vocal Quality
No. Al ergy No. Type Disorders and/or eventual development of benign lesions of
1 AR,BA 0 the true vocal cords because of the inflammatory
2 AR 8 S changes that produce hoarseness, breathiness,
3 AR 4 1 S, 3 Om Low frequency whisper and stridency. In a related study, Yairi et
4 AR, U,AD 0 al 9 found a high incidence of nasal allergies in
5 AR 8 S Hoarse children with chronic hoarseness.
6 AR,ATD 1 Om
7 AR 4 3 S, 1 Om In this study, bronchial asthma was associated
8 AR 1 Om Hoarse with the most frequently found vocal quality disor-
9 AR,BA 2 S ders suggesting that both bronchial asthma and al-
10 AR,BA 1 S lergic rhinitis result in vocal quality disorders. Al-
11 AR,BA 2 1 S, 10m Low intensity lergic rhinitis in conjunction with the other dis-
N=l1 AR, BA, U, 31 24 S, 7 Om Low intensity, orders was associated with hoarseness, breathiness
AD,ATD low frequency,
hoarseness and low vocal intensity.
AR - Allergic rhinitis; BA - Bronchial asthma; U - Urticaria; AD-
Allergic dermatitis; ATD - Atopic dermatitis; S - Substitutions; Om - The specific cause of the disorders was not the
Omissions_ subject of this investigation; however, it is generally
recognized that allergic reactions often result in
Four of the subjects had a 15 dB hearing loss in all either localized or edematous swellings. 3 If the
frequencies tested. Two subjects exhibited a 20 dB respiratory tract is involved, the vocal cords also
loss at 4,000 and 8,000 Hz. Nine of the 11 patients may develop edema and inflammation. 4
had articulation errors; 4 of the 11 had accompany-
ing vocal quality disorders (Table 3). Case history These factors are potentially important for the
analysis revealed that the two patients with neither speech-language pathologist and otolaryngologist in
disorder had essentially normal hearing with a the evaluation and management of vocal quality
slight hearing loss at higher frequencies. disorders. If chronic or persistent hoarseness is the
In addition, the types of allergies were compared reason for therapy, the possibility of allergy as the
to misarticulations by the use of a chi square test. cause should be evaluated carefully, along with
These test results indicated that allergic rhinitis oc- other causes of edema such as disease, trauma, med-
curring either singly or in conjunction with other ication and hormonal imbalance. The importance
disorders Was related to 16 of 18 significant misar- of analyzing these factors is aptly summarized by
Moore,14 who states that the remediation of voice
ticulations. Omission errors were all in the final po-
sition and included the sounds s, z, j. The substitu- disorders encompasses more than voice assessment
tion errors were associated with a fronting phenom- and vocal exercises.
enon, ie, the tongue was placed in an anterior posi- The data obtained in this study on error cate-
tion within the oral cavity. Perhaps swollen tissue gories of substitutions and distortions are similar to
within the respiratory tract thrust the tongue in a that of Templin!S for normative data. Omission er-
forward position for breathing purposes; therefore, rors (15 % of total), however, were about three
resulting in a compensatory speech pattern. An ex- times higher than the 5 % recorded for children 8
ample of the substitution errors is t substituted for years of age. As noted in the results section, these in-
ch (t/ch); s/sh; z/sh; and f/th. Bronchial asthma and creased values are also related to the incidence of
bronchial asthma associated with other disorders hearing loss in subjects with allergic rhinitis. The
had only two significant misarticulations. Three of presence of speech sound omissions in allergy pa-
the five patients with allergic rhinitis and misartic- tients 8 years of age or older may be indicative of a
ulations also had a hearing loss. Specifically, the fluctuating hearing loss and/or other causative fac-
three significant speech sound omission relation- tors.
ships involved a hearing loss.
The finding of allergic rhinitis in association with
diminished hearing and misarticulations is not sur-
DISCUSSION
prising since the literature is replete with reports of
The percentage (44.75 %) of vocal quality dis- allergic rhinitis affecting the eustachian tube and
orders is between five and ten times greater than the middle ear. 1,57 Allergic rhinitis can result in dimin-
percentage (6 %) found in mass screenings in the St. ished hearing and, when chronic, lead to the devel-
Louis metropolitan area. 2 Although the type of opment of serous otitis media. It has been estimated
vocal disorders was not discussed, the authors note that serous otitis may occur in 66 % of children who
that a family history of allergy occurred in over have allergic rhinitis. 7 The presence of fluid in the
25 % of the children with diagnosed vocal quality middle ear causes a conductive hearing loss which
disorders. Significantly, however, a history of re- may range as high as 20-30 dB.' 6 It is difficult to

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280
detect this type of hearing loss because it is often
transient and fluctuating. 6 If this fluctuating hear-
ing loss is present in the early years when articula-
tion is developing, delayed or fa.ulty speech may
result." Thus, it is not uncommon for a young child
with allergic rhinitis to have a history of delayed
speech development. 6
These results may imply that children with aller-
gic rhinitis should receive audiological analysis a.s
well as articulation analysis. In addition, it might
be appropriate for children producing misarticula-
tions to receive impedance screening. The audio-
gram obtained by use of impedance audiometry is
useful in determining whether there is current hear-
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BAKER ETAL
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