Comprehensive Assessment for Resonance Disorders: Typical Components

• Family history of cleft palate, resonance disorders, VPD, and/or speech-language disorders
• Medical history, including history of cleft palate; presence of neurologic conditions or injury (e.g., dysarthria, apraxia, stroke, tumor, trauma); surgical history (e.g., tonsillectomy, adenoidectomy, cleft repair surgery or surgeries); and current medications
• For children, developmental history
• History of speech-language treatment (including speech treatment post cochlear implant)
• History of treatment for temporary or permanent hearing loss
• History of known syndromes and results of prior genetic testing
• History of current or past feeding or swallowing difficulties and nasal regurgitation of food or liquid
• History of atypical nasal congestion, difficulty breathing through the nose, or snoring concerns
• Onset of resonance problem, including how long it has been present, whether it fluctuates, and under what circumstances

• Otoscopic examination
• Immittance testing to assess middle ear function
• Pure-tone air and bone conduction to determine presence and type of hearing loss
• Otoacoustic emissions testing to assess outer hair cell function
• Word recognition (discrimination)
• Speech recognition (closed or open set, depending on age)

• Concerns related to (or history of) nasal regurgitation of food or liquid (may be present in patients with hypernasal resonance secondary to VPD or a fistula).
• When feeding and/or swallowing difficulties are present, instrumental studies may be indicated.

• Visually examine individual for structural differences/abnormalities (e.g., proportion and symmetry) of the craniofacial complex (including face, nose, eyes, ears, skull, and profile).
• Evaluate oral structure and function; assess for
  • symmetry, strength, and movement of oral structures (lips, jaw, tongue, velum);
  • length of the soft palate relative to the depth of the oropharynx;
  • presence of fistulas in the hard and/or soft palate (evaluate for size, location, and patency);
  • signs of possible submucous cleft, including bifid uvula, zona pellucida, or tenting of the velum during phonation;
  • presence and size of tonsillar tissue (large tonsils can play a role in airway and resonance problems); and
  • evidence of past surgeries (e.g., scarring, tissue excision, pharyngeal flap).

• Precedes and determines the need for instrumental assessment.
• Includes assessment of resonance and airflow, classification of speech sound errors, and correlation of perceptual speech data with orofacial exam findings.
  
  See A Guide for Cleft Palate Speech Sampling [PDF] (adapted with permission from Trost-Cardamone, 2013) for a list of stimuli and tasks that can be used. See also Chapman et al. (2016) and Peterson-Falzone et al. (2017) for a listing of the American English Sentence Sample (AESS) developed by Trost-Cardamone (2012) and Kummer (2020b) for a list of syllables and sentences for differential diagnosis. See Peterson-Falzone et al. (2017) for a listing of the UPS Spanish sentence protocol (Cleves et al., 2009).

Speech Sound Production

• Determine if articulation is age appropriate and socially acceptable.
• Differentiate speech sound error types across a variety of speech contexts:
  • In pediatric population—developmental articulation errors and phonological errors (see ASHA’s Practice Portal page on Speech Sound Disorders: Articulation and Phonology)
  • Obligatory distortions (due to abnormal VPD)
  • Compensatory articulation errors
  • Velopharyngeal mislearning errors
  • Errors or distortions consistent with dysarthria or apraxia
  • Distortions secondary to nasal obstruction (e.g., denasalized /m, n/)
• Assess speech intelligibility/understandability and acceptability
• Assess factors that affect intelligibility (e.g., rate of speech)

Resonance

• Standardized measures for resonance assessment are selected with consideration for documented validity and reliability (e.g., Baylis, Chapman, & Whitehill, 2015; Chapman et al., 2016)
• Perceptual rating methods for resonance include interval rating scales, visual analogue scales, categorical scales, and descriptors and definitions (see, e.g., Henningsson et al., 2008; John, Sell, Sweeney, Harding-Bell, & Williams, 2006).
• Using voiced (resonating) sounds, assess for the following:
  • Hypernasality—excessive nasal resonance on vowels and voiced oral consonants.
  • Hyponasality—too little or absent resonance on nasal consonants and adjacent vowels, especially /i/ and /u/.
  • Mixed resonance—elements of inconsistent hypernasality, hyponasality, and/or cul-de-sac resonance in connected speech.
  • Cul-de-sac resonance—sound is muffled and consonants are indistinct due to a blockage at the exit of the nasal, oral, or pharyngeal cavity.
• Use low-tech procedures during speech to confirm or verify what was heard:
  • Feel sides of nose for vibration that might accompany perceived hypernasality.
  • Alternately pinch and then release the nose (sometimes referred to as the cul-de-sac test or nasal occlusion) while individual produces a speech segment—a change in resonance indicates hypernasality.
• Judge severity of abnormal resonance (see ACPA Normal and Hypernasal Speech and the Rochester Institute of Technology Training for listening samples).

Nasal Air Emission

• Using voiceless oral pressure consonants (plosives, fricatives, or affricates):
  • Listen for audible nasal air emission across multiple speaking contexts.
  • Determine whether nasal air emission is pervasive on all pressure-sensitive sounds (obligatory) or is phoneme specific (learned).
  • Listen for presence of weak pressure or no plosive quality on oral pressure consonants (obligatory to VPD).
• Use low-tech procedures during speech to confirm or verify what was heard:
  • Hold mirror under nares to detect nasal air emission—look for fogging during production of voiceless oral pressure consonants.
  • Listen for sound/airflow exiting the nostril by placing one end of a straw or listening tube at nostril entrance and the other end to the examiner's ear.

Voice

• Assess for voice quality and signs of vocal fold pathology (e.g., vocal nodules)—breathiness and low volume may mask hypernasality and nasal air emission.
• May include
  • auditory-perceptual assessment;
  • instrumental assessment;
  • assessment of voice handicap; and
  • referral for ENT assessment.

For more information, see the Assessment section of ASHA’s Practice Portal page on Voice Disorders.

• Helps to explain perceptual speech findings with regard to VP function.
• Recommended when the perceptual speech findings detect hypernasality with or without nasal air emission.
• Assists with planning of intervention.
• Methods include the following:
  • Direct observation via imaging studies (multiview videofluoroscopy, nasopharyngoscopy)
  • Indirect measures (nasometry, pressure-flow studies)
  
  See Comprehensive Assessment for Cleft Lip and Palate: Typical Components for more detailed descriptions of these instrumental measures.

• Referral to cleft palate/craniofacial team for comprehensive evaluation and treatment planning (e.g., surgical)
• Referral to ENT in cases of hyponasality or when concerns suggest the possibility of nasal/nasopharyngeal obstruction
• Referral for x-rays or other imaging studies to look for presence of obstructions in the nasal passage or pharynx that are not visible upon examination (e.g., enlarged adenoids; nasal polyps; tumors)
• Referral to a geneticist if a syndromic etiology is suspected
• Referral for surgical consultation
• Referral to a prosthodontist for evaluation of candidacy for a palatal prosthesis