COVID-19 UPDATES: Find news and resources for audiologists, speech-language pathologists, and the public.
Latest Updates | Telepractice Resources | Email Us

Resonance Disorders

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 Classification of Velopharyngeal Dysfunction [PDF]. 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.


See the Velopharyngeal Dysfunction Evidence Map for summaries of available research on this topic as it relates to resonance disorders.

Speech resonance is the result of the transfer of sound produced by the vocal folds through the vocal tract comprised of the pharynx, oral cavity, and nasal cavity (Kummer, 2020a; Peterson-Falzone, Trost-Cardamone, Karnell, & Hardin-Jones, 2017). The vocal tract filters this sound, selectively enhancing harmonics based on the size and/or shape of the vocal tract. Perceived resonance is the result of this filtered tone.

The velopharyngeal (VP) valve plays an integral role in determining speech resonance; however, other aspects of the vocal tract also contribute to the perceived sound. These include the size and shape of the resonating cavities (pharynx, oral cavity, and nasal cavity), the position of the tongue, and the degree of mouth opening. Opening and closing of valves along the vocal tract (e.g., vocal cords, VP valve, and place of articulation) contribute to the size and shape of the vocal tract.

Normal resonance is achieved through an appropriate balance of oral and nasal sound energy, based on the intended speech sound. Resonance varies for vowels, oral consonants, and nasal consonants and also varies across languages and dialects. Most vowels and vocalic consonants in the English language are predominantly oral. Normal resonance has a range of acceptability and is perceived along a continuum (Peterson-Falzone, Hardin-Jones, & Karnell, 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 and occasionally are due to mislearning (e.g., articulation errors that can lead to the perception of a resonance disorder).

Resonance is a function of sound—not airflow. 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 of air through the nasal cavity during production of pressure consonants. Nasal airflow “errors” may be learned (e.g., nasal fricatives, pharyngeal fricatives, and phoneme-specific nasal emission), or they may be obligatory due to a palatal fistula or VPD. See ASHA's Practice Portal Page on Cleft Lip and Palate for further discussion.

Resonance disorders include the following:

  • Hypernasality—occurs when there is sound energy in the nasal cavity during production of voiced, oral sounds.
  • Hyponasality—occurs when there is not enough nasal resonance on nasal sounds due to a blockage in the nasopharynx or nasal cavity.
  • Cul-de-sac resonance—occurs when sound resonates in a cavity (oral, nasal, or pharyngeal) but is “trapped” and cannot exit because of an obstruction.
  • Mixed resonance—presence of hypernasality, hyponasality, and/or cul-de-sac resonance in the same speech signal.

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—VPD—is reported in the literature for the following disorders and conditions.

References below are made to both VPD and velopharyngeal insufficiency; for clarification between terms, see Classification of Velopharyngeal Dysfunction.

  • Cleft palate is the condition most commonly associated with VPD (Kummer, Marshall, & Wilson, 2015). Overall, up to 30% of individuals who have undergone cleft palate repair experience continued velopharyngeal insufficiency (Ha, Koh, Moon, Jung, & Oh, 2015; Phua & de Chalain, 2008; Witt, Wahlen, Marsh, Grames, & Pilgram, 1998; Zhao et al., 2012).
    • Submucous cleft palate presents with velopharyngeal insufficiency in about 10% to 35% of cases (Nasser, Fedorowicz, Newton, & Nouri, 2008; Weatherly-White, Sakura, Brenner, Steward, & Ott, 1972; Ysunza et al., 2001).
    • Pierre Robin sequence (PRS) typically presents with a wide U-shaped cleft palate, among other aerodigestive tract abnormalities. Resonance disorders are common; however, evidence is mixed as to whether individuals with PRS experience different rates of postsurgical velopharyngeal insufficiency than do individuals with cleft palate alone (Filip et al., 2015; Goudy, Ingraham, & Canady, 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 impairments (van Borsel, 2004).
    • 22q11.2 deletion syndrome (also known as velo-cardio-facial syndrome, DiGeorge syndrome, Shprintzen syndrome, and Sedláčková syndrome) is the most common genetic cause of congenital VPD (Kirschner, 2005); velopharyngeal insufficiency is present in about 75% of individuals (Crockett, Goudy, Chinnadurai, & Wootten, 2014; Kirschner, 2005; Shprintzen & Golding-Kushner, 2008).
  • Other conditions associated with VPD
    • Dysarthria may or may not present with resonance issues, most typically related to discoordination of velopharyngeal valving, prolonged vowel productions that are often accompanied by hypernasality, and neurologic effects on the musculature of the palate and pharynx. VPD “is frequently, but not universally, associated with dysarthria” (Yorkston, Beukelman, Strand, & Hakel, 2010, p. 203).
    • Adenoidectomy may result in persistent VPD in about 1 in 1,500 to 1 in 10,000 patients (Biavati, Rocha-Worley, & Wiet, 2017); this may require surgical or prosthetic management. VPD is persistent when it lasts beyond several weeks (Biavati et al., 2017; Willging & Kummer, 2014).
    • Uvulopalatopharyngoplasty, a common procedure for the correction of obstructive sleep apnea, is associated with velopharyngeal insufficiency as a long-term complication in about 8% of individuals (Tang, Salapatas, Bonzelaar, & Friedman, 2017).
    • Hearing loss is associated with hypernasality, hyponasality, or mixed resonance. Children with cochlear implants may have less disordered resonance than those with hearing aids (Baudonck, Van Lierde, D'haeseleer, & Dhooge, 2015; Fletcher, Mahfuzh, & Hendarmin, 1999; Sebastian, Sreedevi, Lepcha, & Mathew, 2015).

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.

Hypernasality

  • Perceived when there is excessive nasal resonance, typically on vowels, glides, liquids, and, in severe cases, voiced oral consonants (e.g., /b/, /d/, and /ɡ/).
  • High vowels (/u, i/) are most susceptible to effects of hypernasality and are often the first vowels in which the listener notices its presence.
  • Voiced pressure consonants may be perceived as their nasal cognates (e.g., /n/ for /d/ or /m/ for /b/).

Hyponasality

  • Perceived when there is reduced nasal resonance on vowels, sonorants, and nasal consonants.
  • In more severe cases, hyponasality co-occurs with denasalization of nasal consonants (/m/, /n/, and /ŋ/), making them sound more oral in quality (e.g., /b/ for /m/, /d/ for /n/, and /ɡ/ for /ŋ/)

Cul-de-Sac Resonance

  • Sound resonates in one of the cavities of the vocal tract (e.g., nasal, oral, or pharyngeal cavity) but is blocked at the cavity exit due to an obstruction.
  • Both oral and pharyngeal cul-de-sac resonance cause consonants to be “muffled” and indistinct, and the volume of speech to be reduced.
  • Nasal cul-de-sac resonance causes a “tinny” resonance and indistinct speech.

Mixed Resonance

  • Co-occurrence of hypernasality, hyponasality, and/or cul-de-sac resonance in the same speech signal.
  • Hypernasality and hyponasality can occur at different times during connected speech (e.g., with apraxia).
  • Hypernasality and hyponasality may co-occur when VPD and any form of nasopharyngeal obstruction are present.

There are a number of causes of resonance disorders, including velopharyngeal dysfunction, oronasal fistulas, obstruction in the nasal or pharyngeal cavity, and hearing loss. Specific causes are grouped below by type of resonance disorder.

Hypernasality

  • Velopharyngeal dysfunction (VPD) (See Classification of Velopharyngeal Dysfunction [PDF] for terminology and examples.)
    • Structural causes resulting in velopharyngeal insufficiency (e.g., overt, submucous, or occult submucous cleft palate; irregular adenoids, adenoid atrophy [usually in those just getting velo-adenoidal closure]; post-adenoidectomy, enlarged tonsils that intrude into the pharynx and prevent VP closure; post-tonsillectomy [rare but may occur due to scar tissue affecting lateral wall movement]; maxillary advancement; deep pharynx [palatopharyngeal disproportion]; velar hypoplasia or dysplasia; tissue deficit from tumor resection; shrinkage following radiation therapy).

    • Structural anomalies associated with genetic syndromes can also result in hypernasality. These syndromes include 22q11.2 deletion syndrome (also known as velo-cardio-facial, DiGeorge syndrome, Shprintzen syndrome, and Sedláčková syndrome), CHARGE syndrome, Treacher Collins syndrome, Nager syndrome, BOR syndrome, Turner syndrome, Beckwith-Wiedemann syndrome, Stickler syndrome, Kabuki syndrome, Opitz G/BBB syndrome, Jacobsen syndrome, and any syndromic form of Robin sequence (Kummer, 2014; Shprintzen, 1997, 2000; Ysunza, Jackson, & Lozon, 2013).

    • Neurogenic causes resulting in VP incompetency (e.g., traumatic brain injury, stroke, cerebral palsy, apraxia [congenital or acquired], velar paresis/paralysis [e.g., cranial nerve defects], neuromuscular disease [e.g., myasthenia gravis and muscular dystrophy], neurofibromatosis, and neurodevelopmental syndromes such as velo-cardio-facial syndrome, Prader-Willi syndrome, myotonic dystrophy, and nemeline myopathy [Shprintzen, 1997]). Neurogenic causes are often associated with dysarthria and hypotonia.

    • Velopharyngeal mislearning
      • Learned compensatory misarticulations (e.g., glottal stops and pharyngeal fricatives, nasal fricatives, tongue clicks) that develop due to the inability to generate adequate intraoral airflow for consonant production. These productions almost always persist after successful physical management of the VP mechanism. When these errors are present, the adjacent vowels may become nasalized due to coarticulatory effects, thus leading the listener to perceive hypernasality.
      • Lack of auditory feedback in individuals who are deaf or have significant hearing loss. Abnormal resonance is due to an inability to learn nasal and oral contrasts and later monitor resonance normally through auditory feedback.

  • Oronasal fistula (e.g., in individuals with a history of cleft palate; trauma to the oral cavity; or ablative surgery in the oral cavity)
    • May result in hypernasality only if the fistula size is large—small fistulas may cause nasal emission on anterior sounds but not necessarily hypernasality; some fistulas are asymptomatic.

Hyponasality

  • Nasal cavity/nasopharynx obstruction (e.g., enlarged adenoids, restricted pharyngeal cavity space due to maxillary retrusion and other craniofacial anomalies).
  • Swelling (with or without nasal congestion) due to allergic rhinitis, common cold, adenoid hypertrophy, nasopharyngeal polyps, and hypertrophic tonsils.
  • Deviated septum (nasal septum is significantly “off-center”).
  • Choanal atresia (abnormal narrowing of the passageway from the nose to the pharynx).
  • Stenotic nares (narrow nostrils, often seen in patients with cleft lip repair).
  • Unwanted complications of corrective surgery for VPD.
  • Problems with motor planning/execution (apraxia) that result in inconsistent, abnormal VP closure on nasal phonemes.
  • Lack of auditory feedback in individuals who are deaf or have significant hearing loss may result in perceived hyponasality due to atypical tongue position during speech.

Cul-de-Sac Resonance

  • Oral—microstomia (small mouth opening).
  • Nasal—blockage in the anterior part of the nose (e.g., stenotic nares, nasal polyps, or deviated septum).
  • Pharyngeal (most common)—large tonsils/enlarged adenoids; lack of auditory feedback in individuals who are deaf or have significant hearing loss may result in cul-de-sac resonance due to atypical tongue position during speech.

Mixed Resonance

  • Problems with motor planning/execution (apraxia) that result in inconsistent abnormal VP opening and closing.
  • Combination of VPD and any form of nasopharyngeal obstruction—hypernasality and hyponasality may co-occur; nasal resistance does not eliminate nasal resonance completely but prevents nasal consonants from maintaining their integrity (Peterson-Falzone et al., 2010).
  • Lack of auditory feedback in individuals who are deaf or have significant hearing loss may result in mixed resonance problems.

Speech-language pathologists (SLPs) play a central role in the screening, assessment, diagnosis, and treatment of persons 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, 2016b).

For further information regarding the role of the SLP in the management of persons with cleft lip and palate and associated craniofacial conditions, which includes VPD, the reader is referred to ASHA's Practice Portal page on Cleft Lip and Palate.

In cases of resonance disorders in other (noncleft) populations, appropriate roles for SLPs include, but are not limited to, the following:

  • Providing prevention information to individuals and groups known to be at risk for resonance disorders, as well as to individuals working with those at risk
  • Educating other professionals on the needs of individuals with resonance disorders and the role of SLPs in diagnosing and managing resonance disorders
  • Screening (including hearing) of individuals who present with signs and symptoms consistent with a resonance disorder; determining the need for further assessment and/or referral for other services
  • Conducting a comprehensive, culturally and linguistically appropriate assessment of speech and resonance problems associated with resonance disorders, including perceptual and acoustic assessment of speech as well as evaluation of articulation when abnormal productions are noted
  • Conducting and interpreting imaging studies of the velopharynx during speech to assist in diagnosis and treatment planning (e.g., nasopharyngoscopy and videofluoroscopy), when indicated
  • Differentially diagnosing resonance disorders
  • Collaborating with physicians to determine etiology
  • Referring to other professionals to rule out other conditions and to facilitate access to comprehensive services
  • For children with suspected VPD—regardless of cause—referring to a craniofacial or cleft palate team for further assessment
  • Contributing to decisions about the management of resonance disorders, including behavioral speech therapy, as well as surgical and prosthetic treatments
  • Developing treatment plans, providing treatment, documenting progress, and determining appropriate dismissal criteria
  • Counseling individuals with resonance disorders and their families regarding communication-related issues and providing education aimed at preventing further complications relating to these conditions
  • Consulting and collaborating with other professionals, family members, caregivers, and others to facilitate program development and to provide supervision, evaluation, and/or expert advice or opinion, as appropriate
  • Serving as an integral member of an interdisciplinary team working with individuals with resonance disorders and their families/caregivers—see ASHA's resources on interprofessional education/interprofessional practice [IPE/IPP] and person- and family-centered care
  • Remaining informed of research in the area of resonance disorders and helping advance the knowledge base related to the nature and treatment of these conditions
  • Advocating for individuals with resonance disorders and their families at the local, state, and national levels
  • Providing quality control and risk management

As indicated in ASHA's Code of Ethics (ASHA, 2016a), 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 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.

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.

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

Hypernasality

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

Hyponasality

Surgical management for hyponasality involves procedures to correct anatomical sources of obstruction. Procedures include

  • tonsillectomy/adenoidectomy;
  • 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

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

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

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)
  • 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)

Special Populations: Individuals Who Are Deaf or Hard of Hearing

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 Cochlear Implants.

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.

Collaboration in Treatment

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).

Service Delivery

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 Telepractice.
  • 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)

American Speech-Language-Hearing Association. (2016a). Code of ethics [Ethics]. Available from www.asha.org/policy/.

American Speech-Language-Hearing Association. (2016b). Scope of practice in speech-language pathology [Scope of Practice]. Available from www.asha.org/policy/.

Baudonck, N., Van Lierde, K., D'haeseleer, E., & Dhooge, I. (2015). Nasalance and nasality in children with cochlear implants and children with hearing aids. International Journal of Pediatric Otorhinolaryngology, 79, 541–545.

Biavati, M. J., Rocha-Worley, G., & Wiet, G. J. (2017). Velopharyngeal insufficiency. Medscape Online. Retrieved from http://emedicine.medscape.com/article/873018-overview#a7

Cahill, L. M., Turner, A. B., Stabler, P. A., Addis, P. E., Theodoros, D. G., & Murdoch, B. E. (2004). An evaluation of continuous positive airway pressure (CPAP) therapy in the treatment of hypernasality following traumatic brain injury: A report of 3 cases. The Journal of Head Trauma Rehabilitation, 19, 241–253.

Coelho, A. C., Medved, D. M., & Brasolotto, A. G. (2015). Hearing loss and the voice. In F. Bahmad (Ed.), Update on hearing loss (Chapter 6).

Cordero, K. N. (2008). Assessment of cleft palate articulation and resonance in familiar and unfamiliar languages: English, Spanish, and Hmong (Unpublished doctoral dissertation). University of Minnesota, Minneapolis. Retrieved from https://conservancy.umn.edu/bitstream/handle/11299/45420/Cordero_umn_0130E_10007.pdf?sequence=1&isAllowed=y [PDF]

Crockett, D. J., Goudy, S. L., Chinnadurai, S., & Wootten, C. T. (2014). Obstructive sleep apnea syndrome in children with 22q11.2 deletion syndrome after operative intervention for velopharyngeal insufficiency. Frontiers in Pediatrics, 2, 1–5.

Filip, C., Feragen, K. B., Lemvik, J. S., Lindberg, N., Andersson, E. M., Rashidi, M., . . . Høgevold, H. E. (2015). Multidisciplinary aspects of 104 patients with Pierre Robin Sequence. The Cleft Palate-Craniofacial Journal, 5, 732–742.

Fletcher, S. G., Mahfuzh, F., & Hendarmin, H. (1999). Nasalance in the speech of children with normal hearing and children with hearing loss. American Journal of Speech-Language Pathology, 8, 241–248.

Goudy, S., Ingraham, C., & Canady, J. (2011). The occurrence of velopharyngeal insufficiency in Pierre Robin Sequence patients. International Journal of Pediatric Otorhinolaryngology, 75, 1252–1254.

Ha, S., Koh, K. S., Moon, H., Jung, S., & Oh, T. S. (2015). Clinical outcomes of palatal surgery in children with nonsyndromic cleft palate with and without lip. BioMed Research International, 2015. Retrieved from https://www.hindawi.com/journals/bmri/2015/185459/

Hassan, S. M., Malki, K. H., Mesallam, T. A., Farahat, M., Bukhari, M., & Murry, T. (2012). The effect of cochlear implantation on nasalance of speech in postlingually hearing-impaired adults. Journal of Voice, 26, 669.e17–669.e22.

Jackson, M. (2015). Prosthodontics rehabilitation in velopharyngeal insufficiency. Advances in Otorhinolaryngology, 76, 41–49.

Kirschner, R. E. (2005). Palatal anomalies and velopharyngeal dysfunction associated with velo-cardio-facial syndrome. In K. C. Murphy & P. J. Scambler (Eds.), Velo-cardio-facial syndrome: A model for understanding microdeletion disorders (pp. 83 – 104). New York, NY: Cambridge University Press.

Kollara, L., Schenck, G., & Perry, J. (2014). Continuous positive airway pressure (CPAP) therapy for the treatment of hypernasality: A single case study. Perspectives on Speech Science and Orofacial Disorders, 24, 48–58.

Kuehn, D. P. (1997). The development of a new technique for treating hypernasality: CPAP. American Journal of Speech-Language Pathology, 6, 5–8.

Kuehn, D. P., Imrey, P. B., Tomes, L., Jones, D. L., O'Gara, M. M., Seaver, E. J., . . . Wachtel, J. M. (2002). Efficacy of continuous positive airway pressure for treatment of hypernasality. The Cleft Palate-Craniofacial Journal, 39, 267–276.

Kummer, A. W. (2014). Resonance and velopharyngeal dysfunction (VPD). In A. W. Kummer (Ed.), Cleft palate and craniofacial anomalies: Effects on speech and resonance (pp. 182–224). Clifton Park, NY: Cengage Learning.

Kummer, A. W. (2020a). Speech/resonance disorders and velopharyngeal dysfunction (VPD). In A. W. Kummer, Cleft palate and craniofacial conditions: A comprehensive guide to clinical management (pp. 265–299). Burlington, MA: Jones & Bartlett Learning.

Kummer, A. W., Marshall, J. L, & Wilson, M. W. (2015). Non-cleft causes of velopharyngeal dysfunction: Implications for treatment. International Journal of Pediatric Otorhinolaryngology, 79, 286–295.

Lee, A., Brown, S., & Gibbon, F. (2008). Effect of listeners' linguistic background on perceptual judgements of hypernasality. International Journal of Language and Communication Disorders, 43, 487–498.

Nasser, M., Fedorowicz, Z., Newton, J. T., & Nouri, M. (2008). Interventions for the management of submucous cleft palate. Cochrane Database of Systematic Reviews, 23, 1–16.

Nguyen, L. H., Allegro, J., Low, A., Papsin, B., & Campisi, P. (2008). Effect of cochlear implantation on nasality in children. Ear, Nose & Throat Journal, 87,138–140.

Peterson-Falzone, S. J., Hardin-Jones, M. A., & Karnell, M. P. (2010). Cleft palate speech. St. Louis, MO: Mosby.

Peterson-Falzone, S. J., Trost-Cardamone, J. E., Karnell, M. P., & Hardin-Jones, M. A. (2017). The clinician's guide to treating cleft palate speech. St. Louis, MO: Mosby.

Phua, Y. S., & de Chalain, T. (2008). Incidence of oronasal fistulae and velopharyngeal insufficiency after cleft palate repair: An audit of 211 children born between 1990 and 2004. The Cleft Palate-Craniofacial Journal, 45, 172–178.

Sebastian, S., Sreedevi, N., Lepcha, A., & Mathew, J. (2015). Nasalance in cochlear implantees. Clinical and Experimental Otorhinolaryngology, 8, 202–205.

Shprintzen, R. J. (1997). Genetics, syndromes, and communication disorders. San Diego, CA: Singular Publishing Group.

Shprintzen, R. J. (2000). Syndrome identification for speech-language pathology: An illustrated pocket guide. San Diego, CA: Singular Publishing Group.

Shprintzen, R. J., & Golding-Kushner, K. J. (2008). Velo-cardio-facial syndrome: Volume 1. San Diego, CA: Plural Publishing.

Skirko, J. R., Weaver, E. M., Perkins, J. A., Kinter, S., Eblen, L., Martina, J., & Sie, K. C. (2015). Change in quality of life with velopharyngeal insufficiency surgery. Otolaryngology–Head and Neck Surgery, 153, 857–864.

Tang, J. A., Salapatas, A. M., Bonzelaar, L. B., & Friedman, M. (2017). Long-term incidence of velopharyngeal insufficiency and other sequelae following uvulopalatopharyngoplasty. Otolaryngology–Head and Neck Surgery, 156, 606–610.

van Borsel, J. (2004). Voice and resonance disorders in genetic syndromes: A meta-analysis. Folia Phoniatrica et Logopaedica, 56, 83–92.

Weatherly-White, R. C. A., Sakura, C. Y., Brenner, L. D., Steward, J. M., & Ott, J. E. (1972). Submucous cleft palate: Its incidence, natural history, and indications for treatment. Plastic and Reconstructive Surgery, 49, 297–304.

Willadsen, E., & Henningsson, G. (2011). Cross-linguistic perspectives on speech assessment in cleft palate. In S. Howard & A. Lohmander (Eds.), Cleft palate speech: Assessment and intervention (pp. 167–180). West Sussex, United Kingdom: John Wiley & Sons.

Willging, J. P., & Kummer, A. W. (2014). Facial, oral and pharyngeal anomalies. In A. W. Kummer (Ed.), Cleft palate and craniofacial anomalies: Effects on speech and resonance (pp. 225–253). Clifton Park, NY: Cengage Learning.

Witt, P. D., Wahlen, J. C., Marsh, J. L., Grames, L. M., & Pilgram, T. K. (1998). The effect of surgeon experience on velopharyngeal functional outcome following palatoplasty: Is there a learning curve? Plastic Reconstructive Surgery, 102, 1375–1384.

World Health Organization. (2001). International classification of functioning, disability and health. Geneva, Switzerland: Author.

Yorkston, K. M., Beukelman, D. R., Strand, E. A., & Hakel, M. (2010). Management of motor speech disorders in children and adults. Austin, TX: Pro-Ed.

Ysunza, P. A., Jackson, I., & Lozon, C. L. (2013). Diagnosis and management of velopharyngeal insufficiency associated with chromosomal syndromes. Cloning & Transgenesis, 2, 1–5.

Ysunza, P. A., Pamplona, M. C., Mendoza, M., Molina, F., Martinez, P., Garcia-Velasco, M., & Prada, N. (2001). Surgical treatment of submucous cleft palate: A comparative trial of two modalities for palatal closure. Plastic and Reconstructive Surgery, 107, 9–14.

Zhao, S., Xu, Y., Yin, H., Zheng, Q., Wang, Y., Zhong, T., . . . Shi, B. (2012). Incidence of postoperative velopharyngeal insufficiency in late palate repair. Journal of Craniofacial Surgery, 23, 1602–1606.

Acknowledgements

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:

  • Adriane L. Baylis, PhD, CCC-SLP
  • Kelly Nett Cordero, PhD, CCC-SLP
  • Scott Dailey, PhD, CCC-SLP
  • Angela J. Dixon, MA, CCC-SLP
  • Mark Hakel, PhD, CCC-SLP
  • Sara L. Kinter, MA, CCC-SLP
  • Ann W. Kummer, PhD, CCC-SLP
  • Katherine Monaghan McConville, MA, CCC-SLP
  • Robert J. Shprintzen, PhD, CCC-SLP
  • Margaret M. Wilson, MA, CCC-SLP

Citing Practice Portal Pages

The recommended citation for this Practice Portal page is:

American Speech-Language-Hearing Association. (n.d.). Resonance Disorders.  (Practice Portal). Retrieved month, day, year, from www.asha.org/Practice-Portal/Clinical-Topics/Resonance-Disorders/.

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.

ASHA Corporate Partners