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Resonance Disorders

See the Assessment section of the Velopharyngeal Dysfunction Evidence Map for pertinent scientific evidence, expert opinion, and client/caregiver perspective, as they relate to resonance disorders.


Assessment and treatment of resonance disorders may require use of appropriate personal protective equipment.

Assessment includes evaluation of oral, nasal, and velopharyngeal function for speech production. The goal is to help determine if an individual would benefit from speech therapy and/or if medical (i.e., surgical or prosthetic) intervention might be warranted. The SLP conducts the assessment alone or as a member of a collaborative team that may include family members or caregivers, and other relevant professionals (e.g., otolaryngologist, surgeon, or prosthodontist).

Differential diagnosis is important during assessment to distinguish velopharyngeal mislearning from other causes of VPD. This will ensure that appropriate treatment follows. If differential diagnosis cannot be determined during initial assessment, referral to an appropriate team (e.g., craniofacial, cleft palate, or VPD team) would be necessary.

Screening

Screening for suspected resonance disorders does not provide a diagnosis but, rather, identifies the need for additional and/or more comprehensive assessment. Clinicians must take into account the norms of a particular language spoken and consider linguistic variance and/or influence when screening an individual's speech for signs of resonance disorder.

Screening typically includes the following:

Speech screening

  • Obtain a limited speech sample in all languages spoken to look for
    • signs and symptoms of resonance disorder, including sounds affected, consistency of symptoms, and severity;
    • presence of nasal emission (obligatory or learned); and
    • presence and type of articulation errors.
  • Perform an oral exam to look for anatomical/structural differences (e.g., cleft-related, such as submucous cleft, fistula, or bifid uvula; non–cleft-related, such as enlarged tonsils).

See the Assessment section of ASHA's Practice Portal page on Cleft Lip and Palate for further details related to screening in persons with cleft lip and palate.

Hearing screening

  • Conduct a hearing screening to
    • identify individuals with hearing loss who were not previously diagnosed and
    • rule out hearing loss as a possible contributing factor to resonance problems.

See ASHA's Practice Portal pages on Adult Hearing Screening and Childhood Hearing Screening for information about hearing screenings. The outcome of a hearing screening may result in referral for a comprehensive hearing evaluation by an audiologist.

Comprehensive Assessment

See Comprehensive Assessment for Resonance Disorders: Typical Components. Some components of the Comprehensive Assessment for Resonance Disorders are similar to those for cleft lip and palate. See Comprehensive Assessment for Cleft Lip and Palate: Typical Components.

Consistent with the World Health Organization's (WHO) International Classification of Functioning, Disability and Health (ICF) framework (ASHA, 2016a; WHO, 2001), assessment is conducted to identify and describe

  • impairments in body structure and function, including underlying strengths and weaknesses related to resonance factors that affect communication performance;
  • co-morbid deficits or conditions, such as developmental disabilities, syndromes, neuromuscular diseases, or hearing loss;
  • limitations in activity and participation, including functional communication in everyday communication contexts (see, e.g., Skirko et al., 2013);
  • contextual (environmental and personal) factors that serve as barriers to or facilitators of successful communication and life participation; and
  • the impact of communication impairments on quality of life of the individual and family.

See ASHA's resource on the International Classification of Functioning, Disability, and Health (ICF) for examples of ICF handouts specific to selected disorders.

Linguistic Considerations

Clinicians must take into account the norms of a particular language spoken and consider linguistic variance and/or influence when evaluating an individual's speech for signs of resonance disorder.

Individuals who speak a dialect or whose speech is influenced by native languages other than English may speak with a different tone or nasality than native English speakers or speakers of Standard English dialect. These differences (e.g., glottalized tones or nasalized vowels) may affect perceptual judgements of nasality. Consequently, clinicians who are unfamiliar with the linguistic characteristics of the individual's dialect or accent may have difficulty distinguishing a resonance difference from a resonance disorder (Lee, Brown, & Gibbon, 2008).

Regardless of the language spoken, vowels (particularly high vowels) and pressure consonants are most vulnerable to velopharyngeal dysfunction. Clinicians need to consider the presence and frequency of occurrence of these sounds in a particular language, as well as the degree of nasality produced by typical speakers of that language (Cordero, 2008; Willadsen & Henningsson, 2011). The presence of lexical tones (e.g., in tonal languages such as Cantonese) should also be taken into consideration when assessing possible VPD (Cordero, 2008). 

See ASHA's Practice Portal page on Cultural Competence and ASHA's resource Phonemic Inventories Across Languages for additional support.

Considerations for Individuals Who are Deaf or Hard of Hearing

Individuals who are deaf or hard of hearing often exhibit resonance disorders characterized by hypernasality or hyponasality, mixed resonance, or cul-de-sac resonance. In most cases, these resonance problems result from poor control of the VP valve due to the lack of auditory feedback. Despite having normal structure and muscle movement, the VP valve may lack rhythm and timing. These individuals may have speech characteristics including abnormal resonance on vowels and nasal consonants (Coelho, Medved, & Brasolotto, 2015). It is important that other anatomical causes of resonance disorder be ruled out, particularly if hearing loss is secondary to a syndrome.

Content Disclaimer: The Practice Portal, ASHA policy documents, and guidelines contain information for use in all settings; however, members must consider all applicable local, state and federal requirements when applying the information in their specific work setting.