The scope of this page is resonance disorders in children and adults. Resonance disorders—specifically hypernasality—are also discussed in ASHA’s Practice Portal page on Cleft Lip and Palate as they relate to clefting.
Velopharyngeal dysfunction (VPD) is discussed in this page as it relates to resonance disorders. See Possible Causes of Hypernasality and/or Nasal Emission. For a discussion of articulation disorders that may co-occur with VPD and resonance disorders, see ASHA’s Practice Portal page on Cleft Lip and Palate.
Resonance disorders are not voice disorders, although they are often mislabeled as such. Resonance disorders should not be confused with conditions targeted by resonant voice therapy, an approach that emphasizes phonation with the least effort and impact on the vocal folds. See ASHA’s Practice Portal page on Voice Disorders. Resonance, however, depends upon voicing as discussed below.
See the Velopharyngeal Dysfunction Evidence Map for summaries of available research on this topic as it relates to resonance disorders.
Resonance is the modification of sound from the vocal folds and is determined by the size and shape of the vocal tract, including the pharyngeal, oral, and nasal cavities.
Speech resonance is the result of the transfer of sound produced by the vocal folds (source) through the vocal tract (filter). The vocal tract selectively enhances harmonics of the source (voicing) based on the size and/or shape of the supralaryngeal cavities, the pharynx, and the oral and nasal cavities.
The velopharyngeal valve is integral to achieving appropriate speech resonance; however, other aspects of the vocal tract also contribute to perceived resonance. These include
Normal resonance is achieved through an appropriate balance of oral and nasal sound energy, based on the intended speech sound. Resonance varies for vowels, voiced oral consonants, and nasal consonants as well as across languages and dialects. Most vowels and vocalic consonants in the English language are predominantly oral, meaning they are produced with the velopharyngeal port closed or nearly closed. Normal resonance has a range of acceptability and is perceived along a continuum (Peterson-Falzone et al., 2010).
Resonance disorders result from too much or too little nasal and/or oral sound energy in the speech signal. They can result from structural or functional (e.g., neurogenic) causes. Speech-language pathologists (SLPs) use differential diagnosis to determine if issues are related to structural and/or functional causes or if the errors are due to mislearning as the different etiologies require different treatment plans. Articulation errors due to mislearning may be misinterpreted as a resonance disorder.
Resonance disorders should not be confused with nasal airflow errors or distortions. Nasal airflow errors are related to articulation when there is an inappropriate escape or release of air through the nasal cavity during production of pressure consonants—consonants that are produced by bursts of streamed air (i.e., /p, b, t, d, k, g, f, v, s, z, ʃ, t͡ʃ, θ, d͡ʒ, ʒ, ð/). Nasal airflow errors may be categorized into one of the following error types:
See ASHA’s Practice Portal page on Cleft Lip and Palate for further discussion.
Resonance disorders include the following:
Hypernasality should not be confused with nasal air emission. Although some clinicians may use these terms interchangeably, they are distinct symptoms of VPD that typically occur on different speech sounds. Hypernasality is a resonance phenomenon that occurs primarily on vowels, and nasal air emission is an aerodynamic phenomenon that occurs primarily on oral pressure consonants, especially voiceless consonants (Zajac & Vallino, 2016). When VPD is present, both hypernasality and nasal air emission can occur in the same speaker, but they are different entities.
See ASHA’s Practice Portal page on Cleft Lip and Palate for further discussion of nasal air emission, including learned nasal fricatives.
Incidence is the number of new cases of a disorder or condition identified in a specific time period. Prevalence is the number of individuals who are living with the disorder or condition in a given time period.
Given the various etiologies and presentations of resonance disorders, overall incidence and prevalence are unknown. Incidence and prevalence estimates for one cause of resonance disorders—velopharyngeal dysfunction (VPD)—are reported in the literature for the following disorders and conditions.
References below are made to both velopharyngeal insufficiency (VPI) and VPD. VPI refers to structural deficits, and VPD refers to dysfunction that may or may not include structural elements.
Cleft palate, including submucous cleft palate, is the condition most commonly associated with VPD and hypernasality (Kummer et al., 2015; Peterson-Falzone et al., 2010; Zajac & Vallino, 2016). For individuals with nonsyndromic cleft palate following primary palatal surgery, 28.8% exhibited significant hypernasality (Ha et al., 2015). The prevalence of VPI based on the rate of secondary surgery was 8.1%–23.81% (Goudy et al., 2011; Ha et al., 2015; O. Jackson et al., 2013). After secondary management, the rate of persisting hypernasality was 18.2% (Goudy et al., 2011).
Genetic syndromes are often associated with resonance disorders, but the extent of the relationship is difficult to determine given frequently co-occurring voice, cognitive, and/or hearing loss (van Borsel, 2004).
Other conditions or procedures associated with resonance disorders
Signs and symptoms of resonance disorders can vary depending on a number of factors, including the type of resonance disorder and the severity of the condition causing the disorder. Signs and symptoms associated with each type of resonance disorder are listed below.
See ASHA’s Practice Portal page on Cleft Lip and Palate for further discussion of differential diagnosis of obligatory versus learned behaviors.
There are several causes of resonance disorders, including velopharyngeal dysfunction (VPD), oronasal fistulas, obstruction in the nasal or pharyngeal cavity, and hearing loss. Specific causes are grouped below by type of resonance disorder.
Oronasal fistula (e.g., in individuals with a history of cleft palate, trauma to the oral cavity, or ablative surgery in the oral cavity)
Hyponasality and/or mixed resonance is common in individuals with repaired cleft palate, especially those who also have clefts of the lip and alveolar ridge (i.e., primary palate). This is due to the frequent occurrence of either large adenoids and/or anterior nasal cavity anomalies including hypertrophic turbinates and deviated septum that reduce normal nasal resonance for nasal consonants.
SLPs play a central role in the screening, assessment, diagnosis, and treatment of individuals with resonance disorders. The professional roles and activities in speech-language pathology include clinical/educational services (diagnosis, assessment, planning, and treatment); prevention and advocacy; and education, administration, and research. See ASHA’s Scope of Practice in Speech-Language Pathology (ASHA, 2016).
See ASHA’s Practice Portal page on Cleft Lip and Palate for further information regarding the role of the SLP in the management of individuals with cleft lip and palate and associated craniofacial conditions, including velopharyngeal dysfunction.
In cases of resonance disorders in other (noncleft) populations, appropriate roles for SLPs include, but are not limited to, the following:
As indicated in ASHA’s Code of Ethics (ASHA, 2023), SLPs who serve this population should be specifically educated and appropriately trained to do so.
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 the use of appropriate personal protective equipment.
Assessment includes evaluation of oral, nasal, and velopharyngeal (VP) 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 care partners as well as other relevant professionals (e.g., otolaryngologist, surgeon, or prosthodontist).
Differential diagnosis is important during assessment and treatment selection to distinguish VP mislearning from other causes of velopharyngeal dysfunction (VPD). Referral to an appropriate team (e.g., craniofacial, cleft palate, or VPD team) is necessary if differential diagnosis cannot be determined during initial assessment or if it is determined that surgical or prosthodontic treatment is warranted.
Screening for suspected resonance disorders identifies the need for additional and/or more comprehensive assessment but does not provide a diagnosis. Clinicians must consider the norms of a particular language spoken as well as linguistic variance and/or influence when screening an individual’s speech for signs of resonance disorder.
Screening typically includes the following.
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.
See ASHA’s Practice Portal resource, Comprehensive Assessment for Resonance Disorders: Typical Components. Some components of the comprehensive assessment for resonance disorders are similar to those of the comprehensive assessment for cleft lip and palate. See Comprehensive Assessment for Cleft Lip and Palate: Typical Components.
Consistent with the World Health Organization’s International Classification of Functioning, Disability and Health (ICF) framework (ASHA, 2023; World Health Organization, 2001), assessment is conducted to identify and describe
See ASHA’s resource on the International Classification of Functioning, Disability, and Health (ICF) for examples of ICF handouts specific to selected disorders.
Assessment may include instrumental evaluation if available and appropriate. Acoustic/spectral correlates of hypernasality are well known and include (a) reduced amplitude of the first formant (F1); (b) the appearance of a “nasal formant” typically below F1; (c) shifts in the frequency of formants, especially F1; and (d) increased bandwidths of formants. When hypernasality is severe, changes in acoustic/spectral properties of vowels can result in reduced intelligibility of a speaker.
Clinicians must consider the norms of a particular language spoken as well as 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 Mainstream American English dialect. These differences (e.g., glottalized tones or nasalized vowels) may affect perceptual judgments 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 (Bae et al., 2020; Velik et al., 2019).
Regardless of the language spoken, vowels (particularly high vowels) and pressure consonants are most vulnerable to VPD. 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; Lee et al., 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), as tonal languages have been shown to present with different levels of nasalance compared to nontonal languages (see V. T. Nguyen et al., 2019, and D. M. Nguyen et al., 2021, for examples).
See ASHA’s Practice Portal page on Cultural Responsiveness and ASHA’s resource on phonemic inventories and cultural and linguistic information across languages for additional support.
There is no “one size fits all” communication approach for those who are identified as deaf and hard of hearing. Language may be manual (e.g., American Sign Language), spoken (oral/aural), or both (total communication). Individuals identified as deaf and hard of hearing who chose spoken language for communication can 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 limited auditory feedback as a result of the hearing loss. 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 et al., 2015). It is important that other anatomical causes of resonance disorder be ruled out, particularly if hearing loss is secondary to a syndrome. Please see ASHA’s Practice Portal page on Language and Communication of Deaf and Hard of Hearing Children for further information on this population.
See the 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. The goal of treatment is to achieve improved resonance to facilitate functional oral communication.
Consistent with the World Health Organization (2001) framework, treatment is designed to
Treatment procedures and approaches discussed below include
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 consider their linguistic background.
See ASHA’s Practice Portal resource, Treatment Decision Tree for Managing Speech Problems Associated with Cleft Palate and VPD for more information.
Surgical management is the most common treatment for hypernasal speech due to velopharyngeal insufficiency (VPI; structural) and may also be used to treat oronasal fistulas that are symptomatic for speech. Procedures include the following (Tse et al., 2023):
Palate-based surgery, such as double-opposing Z-plasty, soft palate elongation, midline incision, and intravelar veloplasty. These surgeries are done to repair the primary muscle and reconstruct the palate to create favorable anatomy for velopharyngeal (VP) function.
Pharynx-based surgery, such as pharyngeal flap (flap raised from the posterior pharyngeal wall and surgically connected to the velum to close the pharyngeal port at midline while leaving the lateral ports open for nasal breathing and the production of nasal sounds) and sphincter pharyngoplasty (flaps raised from the posterior pharyngeal wall and surgically transposed to a horizontal inset along the posterior pharyngeal wall to reduce the diameter of the VP port).
Augmentation, such as fat grafting to fill in small VP gaps.
Combinations, to include the combination of any of the above surgical options such as double-opposing Z-plasty plus sphincter pharyngoplasty.
Surgical management for hyponasality involves procedures to correct anatomical sources of obstruction. Procedures include
Prosthetic management is uncommon in cases where resonance disorder is anatomically based but may be used for correcting resonance problems that are neurologically based, when surgical options are not recommended for the patient by the surgical team, or in rare cases where surgery has not completely resolved the problem. In cases when a consultation with a prosthodontist is being considered, SLPs may collaborate with that prosthodontist to assist in prosthetic design, positioning, or adjustments for optimal speech and swallowing function (Jackson, 2015).
Prosthetic management may include
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 is due to causes other than structural.
Behavioral speech therapy may be considered for the following:
SLPs and audiologists provide therapy to support the language and manner that match individuals’ communication preferences (e.g., signed language vs. spoken language). Individuals who are deaf and 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 VP function (Hassan et al., 2012; L. H. P. Nguyen et al., 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 Cochlear Implants.
Individuals who are profoundly deaf may benefit from visual and tactile feedback to normalize hypernasal speech (L. H. P. Nguyen et al., 2008).
These feedback techniques may include
Please see ASHA’s Practice Portal page on Language and Communication of Deaf and Hard of Hearing Children for further information on this population.
Community-based SLPs—including private practitioners and school-based 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-based 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.
For further information, please see the Service Delivery section in ASHA’s Velopharyngeal Dysfunction Evidence Map.
This list of resources is not exhaustive, and the inclusion of any specific resource does not imply endorsement from ASHA.
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Content for ASHA’s Practice Portal is developed through a comprehensive process that includes multiple rounds of subject matter expert input and review. ASHA extends its gratitude to the following subject matter experts who were involved in the development of the Resonance Disorders page:
The recommended citation for this Practice Portal page is:
American Speech-Language-Hearing Association. (n.d.). Resonance disorders [Practice portal]. https://www.asha.org/Practice-Portal/Clinical-Topics/Resonance-Disorders/