Treatment section of the Velopharyngeal Dysfunction Evidence Map for pertinent scientific evidence, expert opinion, and client/caregiver perspective, as they relate to resonance disorders.
Treatment is indicated for individuals of all ages when their ability to communicate effectively is impaired because of resonance and related articulation disorders.
Consistent with the WHO (2001) framework, treatment is designed to
- capitalize on strengths and address weaknesses related to underlying structures and functions that affect resonance and articulation;
- facilitate activities and participation by helping the individual acquire new skills and strategies; and
- modify contextual factors to reduce barriers and enhance facilitators of successful communication and participation, including identification and use of appropriate accommodations.
The goal of treatment is to achieve improved resonance and improved articulation sufficient to allow for functional oral communication.
Treatment procedures and approaches discussed below include
- surgical management;
- prosthetic management;
- pharmacologic management; and
- behavioral speech therapy.
Treatment selection considers the cause of the resonance disorder; the appropriateness of treatment for the individual's chronological and developmental age; and the individual's medical status, physical and sensory abilities, cognitive status, and cultural and linguistic background. Goals for individuals who speak a language other than English take into consideration their linguistic background.
Surgical management is the most common treatment for hypernasal speech due to velopharyngeal insufficiency (structural) and may also be used to treat oronasal fistulas that are symptomatic for speech. Procedures include the following:
- Pharyngeal flap—flap raised from the posterior pharyngeal wall and surgically connected to velum to close the pharyngeal port in midline while leaving lateral ports for nasal breathing and production of nasal sounds
- Pharyngeal wall augmentation or palatal injection of fat or other filler to fill in small VP gaps
- Sphincter pharyngoplasty—elevate bilateral myomucosal flaps from the posterior faucial pillars to close the lateral borders of the pharyngeal port.
- Furlow Z-palatoplasty—a primary palate repair technique for cleft palate or submucous cleft palate
- Can be used to revise original repair to slightly elongate the velum
- Can be used with non-cleft short velum if levator veli palatini muscle is abnormally oriented
- Flap surgery to close an oronasal fistula—can use autologous (local) tissue, buccal (inner cheek) tissue, or tissue from the dorsum of the tongue
Surgical management for hyponasality involves procedures to correct anatomical sources of obstruction. Procedures include
- removal of nasal polyps;
- surgery to correct deviated septum;
- surgical removal of tissue or bone of the nasal passage to treat choanal atresia; and
- surgical reconstruction to enlarge stenotic nares.
Prosthetic management is used for correcting resonance problems that result in hypernasality when there are no surgical options or when the individual is unable or unwilling to undergo surgery. SLPs may collaborate with prosthodontists to assist in prosthetic design, positioning, or adjustments for optimal speech and swallowing function (Jackson, 2015).
Prosthetic management may include
- palatal obturator (to occlude an oronasal fistula);
- speech bulb (to occlude the velopharynx when there is velopharyngeal insufficiency);
- palatal lift (to hold the velum up in order to compensate for poor velar mobility); and
- nasal obturator (used for individuals with velopharyngeal insufficiency or incompetency to decrease airflow during speech; can be used when a palatal lift is not an option).
Pharmacologic management is sometimes indicated when swelling or inflammation in the nasal cavity due to allergies or other irritants is causing or contributing to hyponasality. Medications include antihistamines or steroids delivered via nasal sprays or oral medication.
Behavioral speech therapy cannot correct resonance disorders that are due to structural causes. Therapy is considered if it has been determined through an evaluation that the abnormal resonance and/or nasal emission is due to misarticulation rather than structural causes.
Behavioral speech therapy is appropriate for the following:
- Phoneme-specific nasal air emission (PSNE) or phoneme-specific hypernasality with normal VP function
- Techniques and tools for targeting these errors include the following:
- Visual feedback provided by a dental mirror placed under the nose during production of oral target phonemes
- Visual biofeedback provided by the See-Scape™
- Auditory biofeedback provided by the Oral and Nasal Listener™
- Auditory biofeedback provided by a stethoscope (placed against side of nose)
- Plastic tubing or drinking straw for self-monitoring one's own productions (one end is placed at patient's/client's nostril entrance, and the other end is placed by the ear)
- Nasometer to monitor oral versus nasal speech and provide real-time visual feedback in cases of phoneme-specific disorders (see the
Treatment section of ASHA's Practice Portal page on Cleft Lip and Palate)
- Use of established/accurate phonemes to shape those affected by PSNE (e.g., using /t/ to shape /s/)
- Compensatory misarticulations that are still present after structure has been corrected (common in patients with a history of cleft palate)
- Changing articulation placement on affected sounds can have some beneficial effect on perception of resonance (see initial therapy targets and strategies and techniques in the
Treatment section of ASHA's Practice Portal page on Cleft Lip and Palate)
- Articulation errors secondary to apraxia of speech (work on planning/coordination of VP movement)
- Postoperative hypernasality
- Persistent hypernasality (or nasal emission) after VP surgery may benefit from speech therapy with biofeedback (see options above); the potential for adequate VP closure during speech should be confirmed prior to initiating therapy.
- Hypernasality that persists more than a few months post-surgery should be referred to the cleft palate/craniofacial or VPD team for reassessment and consideration of possible surgical revision.
- Muscle weakness/dysarthria resulting in hypernasality
- Compensate for persistent resonance disorder—use techniques specific to dysarthria, including modifying the speech pattern (e.g., clear speech; loud speech; reduced rate of speech).
- Resistance treatment—continuous positive airway pressure (CPAP) for resistance training during speech (Cahill et al., 2004; Kollara, Schenck, & Perry, 2014; Kuehn, 1997; Kuehn et al., 2002)
Individuals who are deaf or hard of hearing often have difficulty monitoring VP function due to lack of, or decreased, auditory feedback. Hearing aids and cochlear implants serve to assist the individual's auditory feedback mechanisms, thereby improving self-monitoring skills.
Cochlear implants have been shown to increase understanding of speech and help improve the resonance of oral speakers (Sebastian et al., 2015). Improved nasalance scores following cochlear implantation demonstrate the role of auditory feedback in helping monitor velopharyngeal function (Hassan et al., 2012; Nguyen, Allegro, Low, Papsin, & Campisi, 2008).
After obtaining hearing aids or receiving cochlear implantation, individuals often benefit from aural (re)habilitation to improve listening and communication skills. Additional goals may address speech (e.g., improving consonant production) and resonance, taking advantage of improved auditory feedback. For information on aural (re)habilitation in children with cochlear implants, see ASHA's Practice Portal page on
Individuals who are profoundly deaf may benefit from visual and tactile feedback to normalize hypernasal speech (Nguyen et al., 2008).
These feedback techniques may include
- visual monitoring of nasal airflow with a mirror, See-Scape™, or nasometer and
- tactile feedback during chewing exercises associated with vibratory sensations in the nasal and facial bones or during humming.
Community-based SLPs—including private practitioners and school SLPs—who are involved in the treatment of individuals with resonance disorders are encouraged to collaborate with cleft palate/craniofacial teams and other appropriate professionals, including otolaryngologists and plastic/craniofacial surgeons, to maximize speech outcomes. School and private practice/clinic-based SLPs are encouraged to refer to these teams as needed to ensure quality of care. See also ASHA's resources on
collaboration and teaming and
interprofessional education/interprofessional practice (IPE/IPP).
In addition to determining the type of speech and language treatment that is optimal for individuals with resonance disorders, SLPs consider other service delivery variables—including format, provider, dosage, timing, and setting—that may affect treatment outcomes.
- Format—whether a person is seen for treatment one-on-one (i.e., individual) or as part of a group; telepractice can be used to deliver face-to-face services remotely. See ASHA's Practice Portal Page on
- Provider—the person providing treatment (e.g., SLP, trained volunteer, caregiver)
- Dosage—the frequency, intensity, and duration of service
- Timing—when the intervention is conducted relative to the diagnosis
- Setting—the location of treatment (e.g., home, community-based, school)