Name: ultrasound images of the tongue: a tutorial for assessment and remediation of speech sound errors
Uploaded: 2017-01-03T15:00:00.000+00:00
Duration: 8 min 32 s
Description: Watch this Scientific Journal Video about Ultrasound Images of the Tongue: A Tutorial for Assessment and Remediation of Speech Sound Errors at JoVE.com

The work was supported by NIH grants R01DC013668 (D. Whalen, PI) and R03DC013152 (J. Preston, PI).

Ethics Statement. When used in research, informed consent and/or assent from children is always required before collecting ultrasound images. When used clinically, clients should be informed of the purpose of the ultrasound imaging. Although diagnostic ultrasound imaging is considered &#34;minimal risk&#34; 30, users should always follow the ALARA principle when using ultrasound, meaning exposure to ultrasound should be as &#34;As Low As Reasonably Achievable&#34;31. This involves limiting acoustic power during imaging and also limiting exposure time. For example, if ultrasound is being used for visual feedback but the participant is not attending to the visual feedback, it would be prudent to discontinue imaging.
1. Collecting Ultrasound Images of the Tongue
NOTE: Technical Considerations. Diagnostic ultrasound probes are used to image the tongue. A frequency range between approximately 3 - 8 MHz with a frame rate of about 30 frames per second is recommended for clinical imaging the tongue 32. 
NOTE: The instructions below apply to the diagnostic Ultrasound System (see Materials Table) with a C6-2 transducer, which was selected based on visual comparison of ultrasound images collected from several transducers available for this system. These instructions are adapted from the diagnostic ultrasound system reference manual for this device and are intended to be an illustrative example for one ultrasound. Many other ultrasound systems are in use, and users should consult the operating manuals of their specific device.
<ol>
	<li>Turn on the machine. When powered on, observe the 2D imaging mode automatically displayed on the screen.
	<ol>
		<li>Wait for the system to complete self-diagnostic and calibration tests. 
		NOTE: The automatically displayed image can be adjusted to optimize the clinician&#39;s view by altering the settings of the instrument. Because the use of ultrasound for speech therapy is new, settings appropriate for imaging the tongue surface during speech are not typically preinstalled and must be installed by a representative from the manufacturer (preferred method), or by the clinician. It is important to have the right settings in order to safely and accurately image the tongue for speech therapy purposes. 
		NOTE: Users should familiarize themselves with the basic operations of their ultrasound equipment be sure they understand how to make adjustments of all controls including depth, intensity and contrast to obtain the best images with their equipment. Power should be set as low as reasonably achievable for safety reasons, with adjustments in Gain to compensate for low power settings.</li>
		<li>To use system preset function, press the PRESETS key on the keyboard.</li>
		<li>Observe the Presets screen. Observe the menu items on the left and selections on the right of the screen.</li>
		<li>Roll the trackball to the menu item on the left of the screen and press the SET key on the control panel. Observe more selections for the selected menu item.</li>
		<li>To save changes and exit the system presets, press the SAVE button at the bottom of the screen. 
		NOTE: Table 1 shows the settings used for images in the video. Note that depth is transducer-dependent. Settings were developed in consultation with Siemens Corporation.</li>
	</ol>
	</li>
	<li>Place a small amount of ultrasound gel on the ultrasound transducer.</li>
	<li>Position the participant comfortably in a chair with feet on the floor, back straight, and chin slightly forward.</li>
	<li>To collect a sagittal image and visualize the tongue from tip to root, position the transducer vertically, making tight contact with the skin underneath the chin and applying a firm but not uncomfortable degree of pressure. Orient the transducer along the midline between the mental spine of the mandible and the hyoid bone.</li>
	<li>Begin scanning with the ultrasound.</li>
	<li>View the screen to verify that the transducer is properly oriented. In these sagittal images, the front of the tongue is on the right of the screen and the back of the tongue is on the left. Angle the ultrasound transducer slightly forward or slightly back depending on what part of the tongue is of interest. 
	NOTE: In some devices, the default settings will display an ultrasound image that is upside down. The user should check the default settings for their device and make adjustments as necessary.</li>
	<li>Instruct the participant to swallow to orient the user to the tongue position relative to the palate.</li>
	<li>Obtain a coronal view to image the tongue from left to right sides. To collect coronal images, rotate the ultrasound transducer 90 degrees. Instruct the participant to sustain sounds requiring midline grooving of the tongue such as /r, s, z, &#643;/.It may be necessary to adjust the transducer slightly further forward or back to visualize tongue grooving for different sounds.</li>
	<li>Once imaging is complete, wipe off excess gel and clean the transducer with ultrasound-approved disinfecting wipes or ultrasound-approved cleansing spray.</li>
</ol>
2. Interpreting Ultrasound Images of the Tongue
<ol>
	<li>Basic interpretation of sagittal images
	<ol>
		<li>In a sagittal view, observe the tongue between two major shadows created by bone, which is opaque to ultrasound: the shadow of the mandible (anterior) and the shadow of the hyoid (posterior). At least one, and preferably both, of these landmarks are visible during tongue imaging. 
		NOTE: If there is air below the tongue tip (as is typically the case when the tongue tip is extended), the extreme end of the tongue tip will not be visible on the ultrasound image.</li>
		<li>Instruct the participant to produce alveolar and velar sounds, such as /t d n/ then /k g/. This will help orient both the participant and the clinician to which side of the image is anterior/tongue tip and which side is posterior/tongue dorsum.</li>
	</ol>
	</li>
	<li>Correct /r/ production
	<ol>
		<li>Instruct the participant to produce and sustain /r/. In a sagittal view of a correct production of /r/, the anterior portion of the tongue will elevate. The back part of the tongue dorsum slopes backwards for a correct /r/ production. Observe that if the probe is off midline or has rotated, the image will change and may be uninterpretable. 
		NOTE: If the production is a &#34;retroflex&#34; /r/, then the tongue tip is raised toward the hard palate and the image of the tongue tip may be lost or may be represented as an artefact (e.g., tongue tip appears to raise through the palate). In a classically &#34;bunched&#34; /r/, the tongue tip and/or blade are either horizontal or angled down toward the floor of the oral cavity, but the anterior portion of the tongue dorsum will be raised. In both cases, the elevated portion of the tongue is narrowing the airspace between the tongue and the palate-that is, it is making a vocal tract constriction. The location of this constriction gives English /r/ its primary palatal place of articulation.</li>
		<li>While the participant is sustaining /r/, visualize the tongue root. 
		NOTE: Depending on the particular type of ultrasound probe being used, this may require angling the probe back toward the hyoid. Perceptually accurate English /r/ requires a secondary constriction in the vocal tract caused by the retraction of the tongue root toward the back pharyngeal wall. The posterior pharyngeal wall cannot typically be visualized with ultrasound, but retraction can be inferred: if the tongue root is retracted, the slope of the tongue surface behind the anterior constriction will be shallow.</li>
		<li>Rotate the probe 90 degrees to obtain a coronal view. Position the probe in the rough vicinity of the highest point of the tongue-about 1/3 of the distance between the chin and the throat in the sagittal plane. 
		NOTE: While the participant is sustaining /r/, some elevation of the lateral margins of the tongue is generally visible. Although the teeth are not visible, it is common for individuals making a bunched type of /r/ to feel some contact with the back molars.</li>
	</ol>
	</li>
	<li>Assessing distorted /r/ production with ultrasound
	<ol>
		<li>Instruct the participant to imitate and sustain /r/. 
		NOTE: In a sagittal view of a distorted production of /r/, the anterior aspect of the tongue is typically low, the tongue dorsum usually is raised high and back. Tongue root retraction is often absent, which is often indicated by a steep or nearly vertical slope of the tongue shape behind the anterior constriction.</li>
		<li>Instruct the participant to imitate /r/ in a number of syllables, such as /&#605;, &#593;r, &#618;r, r&#593;, ri, ru/. Note any contexts that are perceptually correct and identify tongue shapes that are associated with correct vs. incorrect productions. 
		NOTE: Dialect differences will influence articulation; these examples are for American English.</li>
		<li>Rotate the probe 90 degrees to obtain a coronal view and observe the lateral margins of the tongue. Repeat productions of syllables such as /&#605;, &#593;r, &#618;r, r&#593;, ri, ru/. While the participant is sustaining a distorted /r/, the lateral margins of the tongue often remain low on one or both sides.</li>
	</ol>
	</li>
</ol>
3. Using Real-time Ultrasound Images for Feedback to Remediate Speech Sound Errors
<ol>
	<li>Instruct the participant on proper positioning of the ultrasound. Allow the participant to hold the ultrasound transducer if they are able. Alternatively, have the clinical researcher hold the transducer, or clamp the transducer to a microphone stand to keep it steady while the participant leans forward and rests the chin on it, maintaining firm pressure. 
	NOTE: There may be a tendency for the probe to slide around. The clinician should be alert to correct movement of the probe to either side of the midsagittal plane, as the image becomes less consistent and harder to interpret.</li>
	<li>Orient the participant to ultrasound images in sagittal section by teaching them about the parts of the tongue. The participant should be able to trace sample tongue contours on a sagittal ultrasound image. Instruct the participant that /r/ requires both an oral constriction in the front and a pharyngeal constriction in the back. 
	NOTE: It is often helpful to instruct the participant to identify the tip, blade, dorsum and root separately, as these correspond to independently moveable areas of the tongue.</li>
	<li>Request that the participant point to the side of a real-time ultrasound image that represents the anterior and posterior, or &#34;front of the tongue&#34; and &#34;back of the tongue.&#34;</li>
	<li>Introduce the participant to different tongue shapes for /r/ using drawings, ultrasound images, or magnetic resonance images33. Make it clear where the oral and pharyngeal constrictions are, but also acknowledge that every tongue shape is slightly different. 
	NOTE: See 2.2.1 and 2.2.2 for interpreting images from correct /r/ production</li>
	<li>Request that the participant describe 2 major constrictions for /r/ that are visible in sagittal section. If the participant cannot identify the oral and pharyngeal constrictions just described, continue to instruct. 
	NOTE: Participants should be able to report what is described in 3.4, indicating that some portion of the front of the tongue raises up, and that the tongue root moves back (as described in 2.2.1 and 2.2.2)</li>
	<li>Orient the participant to ultrasound images in coronal section. Instruct the participant in the desired tongue shape from left to right. Require that the participant trace the tongue shape, identify the left and right edges, and center line groove. Request that the participant explain the desired shape.</li>
	<li>Attempt to elicit correct /r/ in isolation or in syllables by providing phonetic cues to copy different tongue shapes. 
	NOTE: It can be helpful to provide &#34;targets&#34; on the screen for the participant to match during /r/ production. Targets can be generated using a cursor or by drawing on a transparency placed over the screen. Provide explicit instructions such as &#34;If the tongue line doesn&#39;t match the red target, try doing something differently. Change the way one is saying the sound. Focus on making the dorsum go down,&#34; etc. See Supplement 1 for examples of Articulator Placement Cues.</li>
	<li>Have the participant provide an explanation of what they did correctly or incorrectly after some of their attempts.</li>
	<li>If necessary, use standard shaping strategies such as shaping /l/ to /r/ or /&#593;/ to /r/ while viewing the visual feedback.</li>
	<li>After achieving correct productions, press the Pause button to freeze the image. Discuss how the correct image looks different from previous incorrect productions.</li>
	<li>Practice throughout the session without the ultrasound to provide a break and to offer the opportunity for generalization to speech when visual feedback is not available. 
	NOTE: As the participant achieves more accurate productions, increase the linguistic complexity from syllables to words, phrases, and sentences, and reduce the amount of feedback to facilitate generalization. 
	NOTE: Accuracy of speech targets should be regularly monitored. This can be done perceptually by individuals (preferably who are blind to treatment status) who rate recordings of the sounds that are being trained with the ultrasound.</li>
</ol>

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S., Wrench, A., Sancibrian, S. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=How+To+Get+Started+With+Ultrasound+Technology+for+Treatment+of+Speech+Sound+Disorders.">How To Get Started With Ultrasound Technology for Treatment of Speech Sound Disorders.</a> SIG 5 Perspectives on Speech Science and Orofacial Disorders. 25 (2), 66-80 (2015).</li><li>Boyce, S. E. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=The+articulatory+phonetics+of+/r/+for+residual+speech+errors.">The articulatory phonetics of /r/ for residual speech errors.</a> Seminars in Speech and Language. 36 (4), 257-270 (2015).</li><li>Preston, J. L., Leece, M. 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M. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Tongue+reading:+Comparing+the+interpretation+of+visual+information+from+inside+the+mouth,+from+electropalatographic+and+ultrasound+displays+of+speech+sounds.">Tongue reading: Comparing the interpretation of visual information from inside the mouth, from electropalatographic and ultrasound displays of speech sounds.</a> Clin Linguist Phon. 27 (4), 299-311 (2013).</li><li>Zharkova, N., Gibbon, F. E., Hardcastle, W. J. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Quantifying+lingual+coarticulation+using+ultrasound+imaging+data+collected+with+and+without+head+stabilisation.">Quantifying lingual coarticulation using ultrasound imaging data collected with and without head stabilisation.</a> Clin Linguist Phon. 29 (4), 249-265 (2015).</li></ol>

Siemens Corporation provided a temporary loan of three Acuson X300 ultrasounds for research purposes at no cost to the authors.

Critical Steps within the Protocol
It is essential to obtain clear, interpretable images as described in steps 1.3 and 1.6. Poor image quality renders the procedures meaningless. Additionally, participants must be fully aware of what they are seeing on the screen. Therefore, orienting the participant to the image as described in 3.2 is a step that should be emphasized prior to providing visual feedback training. Additionally, step 3.10, which involves clearly describing differences in tongue shape between the participant&#39;s perceptually accurate and inaccurate tongue shapes, is a critical step to increase awareness of the target tongue shape for a specific speaker.
Modifications and Troubleshooting
Image quality is essential. When image quality is waning, it may be necessary to re-apply gel and/or to check that the probe is making stable contact with the skin.
Additionally, it is important to recognize when the images are not representing what the user intends. For example, when collecting sagittal images, if the probe is positioned in the midsagittal plane (i.e., down the middle of the head), the image will show the groove running down the center line of the tongue. If the probe is positioned to the side, the image will show more of the lateral edge of the tongue. The gross shape of the ultrasound &#34;bright white line&#34; will be similar if the image shows more of the groove or more of the tongue side, but they will not be exactly the same. The user should therefore regularly check the position of the probe to determine whether the images reflect mid-sagittal images, and reposition the probe if necessary.
Limitations of the Technique
Although ultrasound has significant advantages over other approaches to visualizing speech production, it is not without limitations. One primary limitation of ultrasound imaging is that only the tongue is imaged. That is, other structures such the hard or soft palate or the pharyngeal walls are not visible; thus, the relation of the tongue to other structures is not apparent. Additionally, it can be difficult to determine where exactly along the tongue contour the images are collected. For example, when interpreting sagittal images of the tongue, the position of the probe is important to consider, as images may not necessarily be mid-sagittal (i.e., midline) if the probe is offcenter or has been rotated. Additionally, not all participants/clients tolerate the use of ultrasound gel beneath the chin. The mindful user of ultrasound should be aware of both the advantages and the limitations of the technology.
Significance of the Technique with Respect to Existing/Alternative Methods
Ultrasound imaging of the tongue using diagnostic mode can be a fast, safe, and effective technology for visualizing tongue movements in real time 30,32. This information can be used to contrast correct and incorrect productions of speech sounds as a way to understand speech errors and teach desired movements for a variety of speech sounds. Traditional speech therapy methods for assessing and remediating speech sound errors such as /r/ distortions rely on auditory perception. Thus, the speech-language clinician is unaware of the exact nature of the speaker&#39;s tongue movements. Cues are often provided instructing speakers to modify their tongue position without any visual reference to the actual movement. Thus, real-time imaging of the tongue in offers an immediate visualization for shared discussion of speech, which traditionally has been abstract or transient. With respect to current theories on speech motor learning (e.g., schema-based motor learning), ultrasound visual feedback offers a form of knowledge of performance feedback 13,15. This feedback may facilitate the acquisition of new speech motor plans for individuals who have previously had difficulty understanding the target movements.
Ultrasound imaging can be particularly useful for evaluating 26,27 and remediating 2,10,11,12,13,20 speech sound errors that involve the oral and pharyngeal constrictions associated with /r/. Sagittal views can identify if the participant is lacking an anterior constriction or tongue root retraction. Coronal views provide the ability to examine whether there is midline grooving and elevation of the lateral margins of the tongue during /r/ production. Once the elements in error have been properly identified, this information can be used to systematically train new tongue movements, ideally while viewing real-time feedback of the tongue 2,10,11,12,13,20. Methods such as electropalatography or electromagnetic articulography do not allow sufficient visualization of all aspects of the tongue, such as the tongue root, whereas ultrasound can overcome this limitation.
Future Applications or Directions after Mastering This Technique
The protocol outlined here is intended to be broad enough to allow others to follow the procedures regardless of the ultrasound technology available. The procedures are also intended to be flexible enough to meet a variety of clinical research or clinical practice needs. Although the focus throughout this discussion was on the specific context of treatment for /r/, these procedures can readily be adapted when training other speech sounds or when working with a variety of populations. Ultrasound feedback of the tongue can be useful for remediation of lingual sounds other than /r/, including vowels, velar and alveolar stops and nasals, and lingual fricatives and affricates 21,23.
Variations in procedures exist; for example, some researchers have used head stabilization techniques to prevent movement of the vocal tract relative to the ultrasound probe. Such procedures are useful if one intends to measure the contour of the tongue 23,35,36 and stabilization can also overcome some of the problems such as the drift in the position of the probe over time; however, head stabilization during ultrasound imaging of the tongue can lead to practical limitations (e.g., uncomfortable head-mounted devices) and thus the ultrasound user must make decisions about the relative trade-off of such procedures. Studies are underway exploring specific modifications to the procedures (e.g., the amount of practice with ultrasound that is ideal, the role of cueing only oral constrictions vs. oral and pharyngeal constrictions) to determine the methods that are optimally effective. In sum, evidence continues to accumulate that procedures incorporating ultrasound feedback of the tongue can yield improved speech clarity in individuals with speech sound disorders.

Both clinical and research settings have seen an increase in the use of ultrasound imaging to provide visual biofeedback intervention to individuals with speech disorders. One important use of ultrasound imaging for speech-language pathologists is as a visual biofeedback tool during intervention for individuals with speech disorders. With the guidance of a speech-language pathologist, learners can observe real-time video of the shape and movements of their tongue and discuss how these images may differ from the tongue movements needed to properly articulate a speech sound. To conduct such interventions, it is important for users to be competent in the interpretation of ultrasound images as the tongue moves in real time. Knowledge of the range of correct articulatory patterns used by typical speakers is foundational to recognizing erroneous tongue shapes.
The methods described herein address (a) collecting ultrasound images of the tongue, (b) interpreting ultrasound images associated with both correct and incorrect productions of speech sounds, and (c) using real-time ultrasound imaging as a source of visual biofeedback to facilitate speech production changes in individuals with speech sound errors. Although ultrasound can be used to visualize a variety of lingual phonemes, examples here will focus on ultrasound images of the tongue for the /r/ sound (as in red car), which is described as the most common residual error among children acquiring American English 1. It is also the sound that has been most extensively studied in clinical applications of ultrasound to date. 2-14
One important goal in speech (re)habilitation is to facilitate more intelligible speech by teaching articulatory routines that result in perceptually appropriate productions of a target sound or sequence. Therefore, it is critical to understand tongue actions during normal speech and during production of speech errors. Real-time visualization of the tongue can play a highly beneficial role in encouraging a speaker to modify articulatory movements, as it provides the clinician and client with a shared representation of what is actually happening during speech. Without real-time visualization of the tongue, only static pictures or verbal descriptions of target tongue configurations are available to facilitate understanding of the desired articulatory behaviors. In schema-based models of motor learning, visual information about the movements of the tongue during speech is considered a form of &#34;knowledge of performance&#34; feedback (i.e.&#160;it provides specific qualitative information about the movement that occurred)15. Previous research has indicated that detailed knowledge of performance feedback can facilitate acquisition of a novel motor routine16.
Ultrasound has several advantages over other technologies used to visualize speech. With ultrasound, the entire contour of the tongue can be visualized quickly from tip to root. Preparation for ultrasound imaging generally takes less than a minute.
In contrast, electropalatography (EPG) requires a dental impression and the creation of a customized pseudopalate (which may take weeks), and it can take time to adapt to speaking with the pseudo-palate 17. EPG also enables visualization of tongue-palate contact only in the region covered by the pseudopalate and cannot display the tongue root or the overall shape of the tongue. This limits the nature of what aspects of articulation can be effectively targeted with EPG.
Another alternative is electromagnetic articulography (EMA), which can provide general information about tongue shape and movement 18. However, EMA requires sensors to be glued to the tongue and other structures; thus, the set-up for this type of tongue imaging can take 20 - 30 min&#160;and may not be a viable method for frequent use. Thus, ultrasound may be viewed as more practical.
In the specific context of clinical research on the assessment and treatment of /r/ errors, the use of ultrasound has been reported in several studies for individuals with idiopathic speech sound disorders 2,10,11,13,19, hearing impairment 20, childhood apraxia of speech 12,21, and acquired apraxia of speech following a cerebral vascular accident 22. Studies have also reported the use of ultrasound to treat errors on other lingual phonemes such as /s k g l &#643; &#679; / 23,24. Additional populations that may be candidates include individuals with speech disorders related to cleft palate, or individuals learning pronunciation of sounds in a non-native language 25.
Ultrasound imaging may also be useful diagnostically, e.g., to characterize errors in lingual shapes,26,27, or to identify sub-perceptible or covert contrasts in disordered speech 28,29. If precise articulatory measurements are being obtained and compared, it is essential that the ultrasound be stabilized so that the coordinate space for measurement remains reasonably constant. However, it is generally agreed that an unstabilized probe yields information of sufficient quality for clinical diagnosis and treatment applications, which is the focus of the present paper.

<table><tbody><tr><td>ACUSON X300&amp;nbsp; ultrasound with C6-2 probe</td><td>Siemens</td><td>Acuson X300</td><td></td></tr><tr><td>Trasceptic Spray</td><td>Parker labs</td><td>PLI 09-25</td><td></td></tr><tr><td>Acquasonic 100 ultrasound gel</td><td>Parker labs</td><td>01-08</td><td></td></tr></tbody></table>

ultrasound images of the tongue: a tutorial for assessment and remediation of speech sound errors

Diagnostic ultrasound imaging has been a common tool in medical practice for several decades. It provides a safe and effective method for imaging structures internal to the body. There has been a recent increase in the use of ultrasound technology to visualize the shape and movements of the tongue during speech, both in typical speakers and in clinical populations. Ultrasound imaging of speech has greatly expanded our understanding of how sounds articulated with the tongue (lingual sounds) are produced. Such information can be particularly valuable for speech-language pathologists. Among other advantages, ultrasound images can be used during speech therapy to provide (1) illustrative models of typical (i.e.&#160;&#34;correct&#34;) tongue configurations for speech sounds, and (2) a source of insight into the articulatory nature of deviant productions. The images can also be used as an additional source of feedback for clinical populations learning to distinguish their better productions from their incorrect productions, en route to establishing more effective articulatory habits.
Ultrasound feedback is increasingly used by scientists and clinicians as both the expertise of the users increases and as the expense of the equipment declines. In this tutorial, procedures are presented for collecting ultrasound images of the tongue in a clinical context. We illustrate these procedures in an extended example featuring one common error sound, American English /r/. Images of correct and distorted /r/ are used to demonstrate (1) how to interpret ultrasound images, (2) how to assess tongue shape during production of speech sounds, (3), how to categorize tongue shape errors, and (4), how to provide visual feedback to elicit a more appropriate and functional tongue shape. We present a sample protocol for using real-time ultrasound images of the tongue for visual feedback to remediate speech sound errors. Additionally, example data are shown to illustrate outcomes with the procedure.

Figure 1 presents sample sagittal images of correct /r/ in a 9-year-old female. The ultrasound images are paired with magnetic resonance images from the same speaker to demonstrate the similar tongue shape that can be viewed with both technologies.
<img alt="Figure 2" src="/files/ftp_upload/55123/55123fig1.jpg" /> 
Figure 1: Sagittal View of a Magnetic Resonance Image during a Correctly Produced American English /r/ with Ultrasound Image of the Tongue (bottom right) from the Same Participant. In all images, the right side of the image represents anterior and the left represents posterior. Notice the elevation of the anterior tongue (right arrow) and the lowering of the dorsum (left arrow). <a href="https://cloudflare-jove-com.remotexs.ntu.edu.sg/files/ftp_upload/55123/55123fig1large.jpg" target="_blank">Please click here to view a larger version of this figure.</a>
In Figure 2, the same 9-year-old is shown 3 months earlier (before ultrasound visual feedback therapy). Note that the distorted /r/ involves a high posterior tongue position, low tongue tip/blade, and lack of a pharyngeal constriction, yielding a sound perceptually similar to [&#650;]. Correct /r/ productions feature elevation of the anterior tongue, a lowered tongue dorsum, and a posterior narrowing reflecting retraction of the tongue root. Note that a range of tongue shapes are possible for correct /r/.
<img alt="Figure 2" src="/files/ftp_upload/55123/55123fig2.jpg" /> 
Figure 2: Sagittal View of a Magnetic Resonance Image during a Distorted Production of American English /r/ with Ultrasound Image of the Tongue (bottom right) from the Same Participant. In all images, the right side of the image represents anterior and the left represents posterior. Notice the low tongue tip/blade (right arrow) and the raised tongue dorsum (left arrow). <a href="https://cloudflare-jove-com.remotexs.ntu.edu.sg/files/ftp_upload/55123/55123fig2large.jpg" target="_blank">Please click here to view a larger version of this figure.</a>
Figure 3 shows sample correct and incorrect /r/ productions in coronal view. Note the elevation of the sides of the tongue, along with midline grooving, in the correct productions and a relatively flat tongue shape for distorted /r/.
<img alt="Figure 3" src="/files/ftp_upload/55123/55123fig3.jpg" /> 
Figure 3: Sample Coronal Ultrasound Tongue Images of Correct (top) and Distorted (bottom) Productions of American English /r/ In these Coronal Views, the Probe is Positioned Vertically to Image the Posterior Tongue Dorsum. Notice the elevation of the lateral margins of the tongue for the correct /r/, along with a groove in the middle. Notice the flat tongue shape for the distorted /r/. These images are from an EchoBlaster 128 ultrasound. <a href="https://cloudflare-jove-com.remotexs.ntu.edu.sg/files/ftp_upload/55123/55123fig3large.jpg" target="_blank">Please click here to view a larger version of this figure.</a>
To date, studies on ultrasound visual feedback for speech sound errors have involved case series or single subject designs.2,5,9-13,21-23 Widely varying patterns of individual response to treatment have been reported. For many individuals, improvement in sound accuracy can be observed with just a few hours of experimental treatment on /r/. Individuals who do not show immediate gains may still achieve improved production over the course of ultrasound practice. Gains made in the treatment setting almost always require some time to generalize to untreated words or contexts.
Figure 4 shows the average accuracy on words containing /r/ across 11 American English speaking participants ages 10-20 years who were treated for /r/ distortions. The data are from multiple-baseline across-subjects single case designs 13,34. Some of the participants were treated on other sounds as well, although the figure is restricted to accuracy of /r/ in one word position per participant. The vertical axis represents percent of untreated /r/ words judged as correct. The horizontal axis represents separate sessions (spaced approximately 3 - 4 d&#160;apart) in which data were collected. Accuracy of /r/ production at the word level was monitored before, during, and after the 7 treatment sessions. Multiple listeners rated recorded productions of words as either &#34;correct /r/&#34; or &#34;incorrect /r/&#34; based on perceived phonetic accuracy. The box reflects the 7 sessions in which ultrasound biofeedback therapy was provided. Improved /r/ accuracy corresponds with the onset of treatment. Moreover, after 7 sessions, when treatment was withdrawn, an upward trend in accuracy continues, suggesting that retention and generalization continued to occur.
<img alt="Figure 4" src="/files/ftp_upload/55123/55123fig4.jpg" /> 
Figure 4: Mean Accuracy of /r/ in Single Words for 11 Participants Ages 10 - 20 Years Treated for /r/ Distortions. The box represents the sessions in which ultrasound visual feedback treatment occurred. Error bars represent standard deviations. <a href="https://cloudflare-jove-com.remotexs.ntu.edu.sg/files/ftp_upload/55123/55123fig4large.jpg" target="_blank">Please click here to view a larger version of this figure.</a>

Watch this Scientific Journal Video about Ultrasound Images of the Tongue: A Tutorial for Assessment and Remediation of Speech Sound Errors at JoVE.com

Ultrasound Images of the Tongue: A Tutorial for Assessment and Remediation of Speech Sound Errors

Ultrasound imaging can be used to display the shape and movements of the tongue in real time during speech. The images can be used to determine the nature of speech sound errors. Visual feedback of the tongue can be used to facilitate improvements in speech sound production in clinical populations.

Diagnostic ultrasound imaging has been a common tool in medical practice for several decades. It provides a safe and effective method for imaging ...

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21.5K Views.  Syracuse University. Ultrasound imaging can be used to display the shape and movements of the tongue in real time during speech. The images can be used to determine the nature of speech sound errors. Visual feedback of the tongue can be used to facilitate improvements in speech sound production in clinical populations. 

Video: Ultrasound Images of the Tongue: A Tutorial for Assessment and Remediation of Speech Sound Errors

A Protocol for Comprehensive Assessment of Bulbar Dysfunction in Amyotrophic Lateral Sclerosis (ALS)

Improved methods for assessing bulbar impairment are necessary for expediting diagnosis of bulbar dysfunction in ALS, for predicting disease progression across speech subsystems, and for addressing the critical need for sensitive outcome measures for ongoing experimental treatment trials. To address this need, we are obtaining longitudinal profiles of bulbar impairment in 100 individuals based on a comprehensive instrumentation-based assessment that yield objective measures. Using instrumental approaches to quantify speech-related behaviors is very important in a field that has primarily relied on subjective, auditory-perceptual forms of speech assessment1. Our assessment protocol measures performance across all of the speech subsystems, which include respiratory, phonatory (laryngeal), resonatory (velopharyngeal), and articulatory. The articulatory subsystem is divided into the facial components (jaw and lip), and the tongue. Prior research has suggested that each speech subsystem responds differently to neurological diseases such as ALS. The current protocol is designed to test the performance of each speech subsystem as independently from other subsystems as possible. The speech subsystems are evaluated in the context of more global changes to speech performance. These speech system level variables include speaking rate and intelligibility of speech.
The protocol requires specialized instrumentation, and commercial and custom software. The respiratory, phonatory, and resonatory subsystems are evaluated using pressure-flow (aerodynamic) and acoustic methods. The articulatory subsystem is assessed using 3D motion tracking techniques. The objective measures that are used to quantify bulbar impairment have been well established in the speech literature and show sensitivity to changes in bulbar function with disease progression. The result of the assessment is a comprehensive, across-subsystem performance profile for each participant. The profile, when compared to the same measures obtained from healthy controls, is used for diagnostic purposes. Currently, we are testing the sensitivity and specificity of these measures for diagnosis of ALS and for predicting the rate of disease progression. In the long term, the more refined endophenotype of bulbar ALS derived from this work is expected to strengthen future efforts to identify the genetic loci of ALS and improve diagnostic and treatment specificity of the disease as a whole. The objective assessment that is demonstrated in this video may be used to assess a broad range of speech motor impairments, including those related to stroke, traumatic brain injury, multiple sclerosis, and Parkinson disease.

A Protocol for Comprehensive Assessment of Bulbar Dysfunction in Amyotrophic Lateral Sclerosis ALS

Objective assessments of the physiological mechanisms that support speech are needed to monitor disease onset and progression in persons with ALS and to quantify treatment effects in clinical trials. In this video, we present a comprehensive, instrumentation-based protocol for quantifying speech motor performance in clinical populations.

Improved methods for assessing bulbar impairment are necessary for expediting diagnosis of bulbar dysfunction in ALS, for predicting disease progression ...

Medicine

Coordinate Mapping of Hyolaryngeal Mechanics in Swallowing

Characterizing hyolaryngeal movement is important to dysphagia research. Prior methods require multiple measurements to obtain one kinematic measurement whereas coordinate mapping of hyolaryngeal mechanics using Modified Barium Swallow (MBS) uses one set of coordinates to calculate multiple variables of interest. For demonstration purposes, ten kinematic measurements were generated from one set of coordinates to determine differences in swallowing two different bolus types. Calculations of hyoid excursion against the vertebrae and mandible are correlated to determine the importance of axes of reference.
To demonstrate coordinate mapping methodology, 40 MBS studies were randomly selected from a dataset of healthy normal subjects with no known swallowing impairment. A 5 ml thin-liquid bolus and a 5 ml pudding swallows were measured from each subject. Nine coordinates, mapping the cranial base, mandible, vertebrae and elements of the hyolaryngeal complex, were recorded at the frames of minimum and maximum hyolaryngeal excursion. Coordinates were mathematically converted into ten variables of hyolaryngeal mechanics.
Inter-rater reliability was evaluated by Intraclass correlation coefficients (ICC). Two-tailed t-tests were used to evaluate differences in kinematics by bolus viscosity. Hyoid excursion measurements against different axes of reference were correlated. Inter-rater reliability among six raters for the 18 coordinates ranged from ICC = 0.90 - 0.97. A slate of ten kinematic measurements was compared by subject between the six raters. One outlier was rejected, and the mean of the remaining reliability scores was ICC = 0.91, 0.84 - 0.96, 95% CI. Two-tailed t-tests with Bonferroni corrections comparing ten kinematic variables (5 ml thin-liquid vs. 5 ml pudding swallows) showed statistically significant differences in hyoid excursion, superior laryngeal movement, and pharyngeal shortening (p &#60; 0.005). Pearson correlations of hyoid excursion measurements from two different axes of reference were: r = 0.62, r2 = 0.38, (thin-liquid); r = 0.52, r2 = 0.27, (pudding).
Obtaining landmark coordinates is a reliable method to generate multiple kinematic variables from video fluoroscopic images useful in dysphagia research.

Coordinate mapping is a method of documenting salient features of hyolaryngeal biomechanics in the pharyngeal phase of swallowing. This methodology uses image analysis software to record coordinates of anatomical landmarks. These coordinates are imported into an excel macro and translated into kinematic variables of interest useful in dysphagia research.

Characterizing hyolaryngeal movement is important to dysphagia research. Prior methods require multiple measurements to obtain one kinematic measurement ...

Measuring Oral Fatty Acid Thresholds, Fat Perception, Fatty Food Liking, and Papillae Density in Humans

Emerging evidence from a number of laboratories indicates that humans have the ability to identify fatty acids in the oral cavity, presumably via fatty acid receptors housed on taste cells. Previous research has shown that an individual&#39;s oral sensitivity to fatty acid, specifically oleic acid (C18:1) is associated with body mass index (BMI), dietary fat consumption, and the ability to identify fat in foods. We have developed a reliable and reproducible method to assess oral chemoreception of fatty acids, using a milk and C18:1 emulsion, together with an ascending forced choice triangle procedure. In parallel, a food matrix has been developed to assess an individual&#39;s ability to perceive fat, in addition to a simple method to assess fatty food liking. As an added measure tongue photography is used to assess papillae density, with higher density often being associated with increased taste sensitivity.

Oral chemoreception of fatty acids and the association with diet and fatty food preferences may enable the identification of mechanisms involved with the development of obesity and why dietary changes may be difficult for many individuals.

Emerging evidence from a number of laboratories indicates that humans have the ability to identify fatty acids in the oral cavity, presumably via fatty ...

Neuroscience

In Vivo Evaluation of the Mechanical and Viscoelastic Properties of the Rat Tongue

The tongue is a highly innervated and vascularized muscle hydrostat on the floor of the mouth of most vertebrates. Its primary functions include supporting mastication and deglutition, as well as taste-sensing and phonetics. Accordingly, the strength and volume of the tongue can impact the ability of vertebrates to accomplish basic activities such as feeding, communicating, and breathing. Human patients with sleep apnea have enlarged tongues, characterized by reduced muscle tone and increased intramuscular fat that can be visualized and quantified by magnetic resonance imaging (MRI). The abilities to measure force generation and viscoelastic properties of the tongue constitute important tools for obtaining functional information to correlate with imaging data. Here, we present techniques for measuring tongue force production in anesthetized Zucker rats via electrical stimulation of the hypoglossal nerves and for determining the viscoelastic properties of the tongue by applying passive Lissajous force/deformation curves.

In Vivo Evaluation of the Mechanical and Viscoelastic Properties of the Rat Tongue

We describe a surgical procedure in an anesthetized rat model for determining the muscle tone and viscoelastic properties of the tongue. The procedure involves specific stimulation of the hypoglossal nerves and application of passive Lissajous force/deformation curves to the muscle.

The tongue is a highly innervated and vascularized muscle hydrostat on the floor of the mouth of most vertebrates. Its primary functions include ...

&#181;Tongue: A Microfluidics-Based Functional Imaging Platform for the Tongue In Vivo

Intravital fluorescence microscopy is a tool used widely to study multicellular dynamics in a live animal. However, it has not been successfully used in the taste sensory organ. By integrating microfluidics into the intravital tongue imaging window, the &#181;Tongue provides reliable functional images of taste cells in vivo under controlled exposure to multiple tastants. In this paper, a detailed step-by-step procedure to utilize the &#181;Tongue system is presented. There are five subsections: preparing of tastant solutions, setting up of a microfluidic module, sample mounting, acquiring functional image data, and data analysis. Some tips and techniques to solve the practical issues that may arise when using the &#181;Tongue are also presented.

 &#181;Tongue: A Microfluidics-Based Functional Imaging Platform for the Tongue In Vivo

The article introduces the &#181;Tongue (microfluidics-on-a-tongue) device for functional taste cell imaging in vivo by integrating microfluidics into an intravital imaging window on the tongue.

Intravital fluorescence microscopy is a tool used widely to study multicellular dynamics in a live animal. However, it has not been successfully used in ...

Endoscopic Approach for Studying Laryngeal Dysfunction in Rodents

Minimally Invasive Murine Laryngoscopy for Close&#45;Up Imaging of Laryngeal Motion During Breathing and Swallowing

The larynx is an essential organ in mammals with three primary functions - breathing, swallowing, and vocalizing. A wide range of disorders are known to impair laryngeal function, which results in difficulty&#160;breathing (dyspnea), swallowing impairment (dysphagia), and/or voice impairment (dysphonia). Dysphagia, in particular, can lead to aspiration pneumonia and associated morbidity, recurrent hospitalization, and early mortality. Despite these serious consequences, existing treatments for laryngeal dysfunction are largely aimed at surgical and behavioral interventions that unfortunately do not typically restore normal laryngeal function, thus highlighting the urgent need for innovative solutions.
To bridge this gap, we have been developing an experimental endoscopic approach to investigate laryngeal dysfunction in murine (i.e., mouse and rat) models. However, endoscopy in rodents is quite challenging due to their small size relative to current endoscope technology, anatomical differences in the upper airway, and the necessity for anesthesia to optimally access the larynx. Here, we describe a novel transoral laryngoscopy approach that permits close-up, unobstructed video imaging of laryngeal motion in mice and rats. Critical steps in the protocol include precise anesthesia management (to prevent overdosing that abolishes swallowing and/or risks respiratory distress-related mortality) and micromanipulator control of the endoscope (for stable video recording of laryngeal motion by a single researcher for subsequent quantification).
Importantly, the protocol can be performed over time in the same animals to study the impact of various pathological conditions specifically on laryngeal function. A novel advantage of this protocol is the ability to visualize airway protection during swallowing, which is not possible in humans due to epiglottic inversion over the laryngeal inlet that obstructs the glottis from view. Rodents therefore provide a unique opportunity to specifically investigate the mechanisms of normal versus pathological laryngeal airway protection for the ultimate purpose of discovering treatments to effectively restore normal laryngeal function.

This protocol describes a serial transoral laryngoscopy approach for mice and rats that permits close-up, unobstructed video imaging of the larynx during breathing and swallowing using an optimized anesthetic regimen and finely tuned endoscopic manipulation techniques.

The larynx is an essential organ in mammals with three primary functions - breathing, swallowing, and vocalizing. A wide range of disorders are known to ...

Image Acquisition using Portable Sonography for Emergency Airway Management

With its increasing popularity and accessibility, portable ultrasonography has been rapidly adapted not only to improve the perioperative care of patients, but also to address the potential benefits of employing ultrasound in airway management. The benefits of point of care ultrasound (POCUS) include its portability, the speed at which it can be utilized, and its lack of invasiveness or exposure of the patient to radiation of other imaging modalities.
Two primary indications for airway POCUS include confirmation of endotracheal intubation and identification of the cricothyroid membrane in the event a surgical airway is required. In this article, the technique of using ultrasound to confirm endotracheal intubation and the relevant anatomy is described, along with the associated ultrasonographic images. In addition, identification of the anatomy of the cricothyroid membrane and the ultrasonographic acquisition of appropriate images to perform this procedure are reviewed.
Future advances include utilizing airway POCUS to identify patient characteristics that might indicate difficult airway management. Traditional bedside clinical exams have, at best, fair predictive values. The addition of ultrasonographic airway assessment has the potential to improve this predictive accuracy. This article describes the use of POCUS for airway management, and initial evidence suggests that this has improved the diagnostic accuracy of predicting a difficult airway. Given that one of the limitations of airway POCUS is that it requires a skilled sonographer, and image analysis can be operator dependent, this paper will provide recommendations to standardize the technical aspects of airway ultrasonography and promote further research utilizing sonography in airway management. The goal of this protocol is to educate researchers and medical health professionals and to advance the research in the field of airway POCUS.

Point of care ultrasound (POCUS) is increasingly being utilized in airway management. Presented here are some clinical utilities of POCUS, including differentiating endotracheal and esophageal intubation, identification of the cricothyroid membrane in the event a surgical airway is required, and measuring anterior neck soft tissue to predict difficult airway management.

With its increasing popularity and accessibility, portable ultrasonography has been rapidly adapted not only to improve the perioperative care of ...

Point-of-Care Ultrasound: A Review of Ultrasound Parameters for Predicting Difficult Airways

Airway management remains a crucial part of perioperative care. The conventional approach to assessing potentially difficult airways emphasizes the LEMON method, which looks for and evaluates the Mallampati classification, signs of obstruction, and neck mobility. Clinical findings help predict a higher likelihood of difficult tracheal intubation, but no clinical result reliably excludes difficult intubation. Ultrasound as an adjunct to clinical examination can provide the clinician with a dynamic anatomical airway assessment, which is impossible with clinical examination alone. In the hands of anesthesiologists, ultrasound is becoming more popular in the perioperative period. This method is particularly applicable for identifying proper endotracheal tube positioning in specific patient populations, such as those who are morbidly obese and patients with head and neck cancer or trauma. The focus is on identifying the normal anatomy, correctly positioning the endotracheal tube, and refining the parameters that predict difficult intubation. Several ultrasound measurements are clinical indicators of difficult direct laryngoscopy in the literature. A meta-analysis revealed that the distance from the skin to the epiglottis (DSE) is most associated with a difficult laryngoscopy. An ultrasound of the airway could be applied in routine practice as an adjunct to the clinical examination. A full stomach, rapid sequence intubation, gross visual anatomical abnormalities, and restricted neck flexibility prevent using ultrasound to assess the airway. The airway evaluation is performed with a linear array transducer of 12-4 MHz, with the patient in the supine position, with no pillow, and with the head and neck in a neutral position. The central axis of the neck is where the ultrasound parameters are measured. These image acquisitions guide the standard ultrasound examination of the airway.

A point-of-care ultrasound (POCUS) is a simple, non-invasive, and portable tool that enables dynamic airway assessment. Several studies have attempted to determine the role of ultrasound parameters as an adjunct to clinical examination in predicting difficult laryngoscopies.

Airway management remains a crucial part of perioperative care. The conventional approach to assessing potentially difficult airways emphasizes the LEMON ...

Objectification of Tongue Diagnosis in Traditional Medicine, Data Analysis, and Study Application

Tongue diagnosis is an essential technique of traditional Chinese medicine (TCM) diagnosis, and the need for objectifying tongue images through image processing technology is growing. The present study provides an overview of the progress made in tongue objectification over the past decade and compares segmentation models. Various deep learning models are constructed to verify and compare algorithms using real tongue image sets. The strengths and weaknesses of each model are analyzed. The findings indicate that the U-Net algorithm outperforms other models regarding precision accuracy (PA), recall, and mean intersection over union (MIoU) metrics. However, despite the significant progress in tongue image acquisition and processing, a uniform standard for objectifying tongue diagnosis has yet to be established. To facilitate the widespread application of tongue images captured using mobile devices in tongue diagnosis objectification, further research could address the challenges posed by tongue images captured in complex environments.

The present study employed U-Net and other deep learning algorithms to segment a tongue image and compared the segmentation results to investigate the objectification of tongue diagnosis.

Tongue diagnosis is an essential technique of traditional Chinese medicine (TCM) diagnosis, and the need for objectifying tongue images through image ...

Technique for Salivary Gland Ultrasound Examination of Sjogren's Syndrome

Ultrasonographic Evaluation of Salivary Glands for Sjogren's Syndrome: Diagnostic and Monitoring Insights

Sjogren's syndrome (SS) is a chronic autoimmune condition commonly affecting the exocrine glands, causing oral or ocular dryness and extraglandular manifestations including arthralgia, cytopenia, and lymphoma. The presence of autoantibodies against SSA/Ro, labial salivary gland biopsy, ocular staining, Schirmer's test, or salivary flow assessment are included in the current classification criteria of SS. However, the availability and invasiveness of these procedures limit their widespread use in clinical settings. Salivary gland ultrasonography (SGUS) is a non-invasive imaging modality for the evaluation of the salivary gland parenchyma and is increasingly utilized to aid diagnosis and monitoring in SS. 
This article presents the protocol of SGUS for image acquisition at the parotid and submandibular glands. The objective is to present a standardized, reproducible, and practical approach to diagnostic SGUS for SS in daily clinical settings. Major salivary glands are scanned in a stepwise approach, beginning at the angle of the mandible for the superficial lobe of the parotid gland, followed by the deep lobe below the ramus of the mandible. Submandibular areas are then scanned for the submandibular glands. The steps in obtaining salivary gland images at each anatomical site are explained in the accompanying video. The echogenicity and echotexture at the thyroid gland are taken as a reference. The homogeneity, the presence and distribution of hypoechoic areas within the glands, and the border of the salivary glands are examined. The sizes and features of intra-/peri-glandular lymph nodes are recorded. The most distinctive sonographic feature in SS is glandular heterogeneity with the presence of hypoechoic/hyperechoic areas within the glands. 
In summary, while SGUS cannot diagnose SS on its own, it can supplement the current classification criteria of SS and guide the clinical decision for salivary gland biopsy to support the diagnosis of SS in patients with sicca syndrome or suspicious systemic features, combined with autoantibody testing.

Author Spotlight: A Focus on Standardized Salivary Gland Ultrasound Protocol in Connective Tissue Disease Research

Salivary gland ultrasonography is a promising tool for the diagnosis and evaluation of disease activity and complications in Sjogren's syndrome (SS). The scanning technique for salivary gland ultrasound examination relevant to SS is described in the article.

Sjogren's syndrome (SS) is a chronic autoimmune condition commonly affecting the exocrine glands, causing oral or ocular dryness and extraglandular ...

Ultrasound Images of the Tongue: A Tutorial for Assessment and Remediation of Speech Sound Errors

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