Comprehensive Assessment for Resonance Disorders: Typical Components

Note: 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 for comparison.

Area Components
Case History
  • 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
Audiologic Assessment
  • 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)
See ASHA’s Practice Portal page on Hearing Loss in Children for information about full audiologic assessment.
Feeding and Swallowing
  • 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.
See ASHA’s Practice Portal pages on Pediatric Feeding and Swallowing and Adult Dysphagia. See also ASHA’s Practice Portal page on Cleft Lip and Palate for information related to feeding and swallowing concerns in that population.
Oral Mechanism Examination
  • 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).
Perceptual Evaluation of Speech
  • 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)


  • 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.


  • 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.

Instrumental Evaluation of Velopharyngeal Function
  • 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.
Other Medical Examinations
  • 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

Note. VPD = velopharyngeal dysfunction; ENT = ear, nose, and throat.


Baylis, A., Chapman, K., & Whitehill, T. L. (2015). Validity and reliability of visual analog scaling for assessment of hypernasality and audible nasal emission in children with repaired cleft palate. The Cleft Palate-Craniofacial Journal, 52, 660–670.

Chapman, K. L., Baylis, A., Trost-Cardamone, J., Cordero, K. N., Dixon, A., Dobbelsteyn, C., . . . Sell, D. (2016). The Americleft Speech Project: A training and reliability study. The Cleft Palate-Craniofacial Journal, 53, 93–108.

Cleves, M., Hanayama, M., Tavera, M. C., Echeverry, M., Arboledas, C., Lizarraga, K., & Bermudez, L. (2009, September). Reliability of the perceptual evaluation of MP3 speech samples. Paper presented at the 11th International Congress on Cleft Lip and Palate and Related Craniofacial Anomalies, Fortaleza, Brazil.

Henningsson, G., Kuehn D., Sell, D., Sweeney, T., Trost-Cardamone, J., & Whitehill, T. (2008). Universal parameters for reporting speech outcomes in individuals with cleft palate. The Cleft Palate-Craniofacial Journal, 45, 1–17.

John, A., Sell, D., Sweeney, T., Harding-Bell, A., & Williams, A. (2006). The cleft audit protocol for speech—Augmented: A validated and reliable measure for auditing cleft speech. The Cleft Palate-Craniofacial Journal, 43, 272–288.

Kummer, A. W. (2020b). Speech and resonance assessment. In A. W. Kummer (Ed.), Cleft palate and craniofacial conditions: A comprehensive guide to clinical management (pp. 303–330). Burlington, MA: Jones & Bartlett Learning.

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.

Trost-Cardamone, J. E. (2012, April). American English Sentence Sample: A controlled sample for assessing cleft palate speech outcome. Paper presented at the Meeting of the American Cleft Palate–Craniofacial Association, San Jose, CA.

Trost-Cardamone, J. (2013). Cleft palate speech: A comprehensive 2-part set. Rockville, MD: American Speech-Language-Hearing Association.

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