Comprehensive Assessment for Cleft Lip and Palate and Resonance

Case History/Chart Review

  • Family history of cleft palate, VPD, resonance and/or speech and language disorders
  • Language(s) used, including primary language spoken in the home
  • Prenatal and birth/delivery history
  • Developmental history
  • Medical history, such as
    • medical diagnoses,
    • syndromic diagnosis,
    • surgical history,
    • history of ear infections/fluid,
    • history of treatment for temporary or permanent hearing loss,
    • history of ventilation tube placement,
    • history of allergies and any observation of atypical nasal congestion,
    • history of neurologic conditions or injury,
    • current medications,
    • 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, and
    • onset of resonance problem (if present), including how long it has been present, whether it fluctuates, and under what circumstances
  • Surgical history relevant to cleft lip and palate (including date and ages of procedures), such as
    • cleft lip,
    • cleft palate,
    • mandibular distraction,
    • fistula repair,
    • pharyngoplasty,
    • alveolar bone graft,
    • orthognathic surgery, and
    • nasal/lip revision
  • Other surgical history, such as
    • tonsillectomy and/or adenoidectomy and
    • frenectomy
  • Concerns regarding
    • feeding,
    • breathing or snoring,
    • hearing, and
    • vision
  • Family’s and other communication partners’ perception of speech intelligibility and resonance
  • Teacher’s perception of the child’s speech and how it compares with the speech of peers in the classroom
  • School history
  • History of speech and language therapy, including any current therapy
  • Psychosocial concerns or issues
  • Family’s perspectives on their quality of life
  • Individual’s perspectives on their quality of life (see, e.g., Hall et al., 2013)

Audiologic Assessment

  • Otoscopic examination
  • Immittance testing to assess middle ear function
  • Pure-tone air and bone conduction to determine the presence and type of hearing loss
  • Otoacoustic emissions testing to assess outer hair cell function, when appropriate
  • Speech awareness threshold or speech reception threshold depending on age/ability
  • Speech discrimination testing (closed or open set, depending on age)

See the American Speech-Language-Hearing Association’s (ASHA’s) Practice Portal page on Hearing Loss in Children for information about full audiologic assessment conducted by an audiologist.

Feeding and Swallowing Assessment

  • Observation and assessment of feeding of the infant with a cleft palate.
  • 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).
  • Completing objective assessments, including fiber-optic endoscopic evaluation of swallowing and videofluoroscopic swallowing study.
  • Feeding assessment and expectations are based on the child’s age, the child’s neurologic and developmental status, and whether or not palate repair has been completed.
  • Selecting appropriate nipples and bottles for feeding newborns.

If the individual is a candidate for surgery or has undergone surgery, further considerations may be necessary. Please see ASHA’s Practice Portal page on Cleft Lip and Palate for specific information. For general information, please see ASHA’s Practice Portal page on Pediatric Feeding and Swallowing.

Oral Mechanism Examination

  • Visually examine the child for structural differences/abnormalities (e.g., proportion and symmetry) of the craniofacial complex, including the face, nose, eyes, ears, skull, and profile.
  • Assess the oral cavity for
    • Symmetry, strength, and movement of oral structures (lips, jaw, tongue, velum);
    • abnormalities of the
      • tongue (e.g., macroglossia, ankyloglossia, asymmetry) and tongue function,
      • lip and nose structures,
      • uvula (including bifidity), and
      • hard palate (e.g., presence of cleft, fistula, or narrow/collapsed maxilla);
    • length of the soft palate relative to the depth of the oropharynx;
    • presence and size of tonsillar tissue (large tonsils can play a role in airway and resonance problems);
    • dentition and occlusal status;
    • fistulae in the hard and/or soft palate (evaluate for size, location, and patency); and
    • evidence of prior palatal or pharyngeal surgery (scarring, placement of sphincter or pharyngeal flap, buccal flap).
  • For individuals with no history of cleft palate, visually examine the hard and soft palate—look for signs of possible submucous cleft palate, such as
    • a bifid uvula,
    • a bony notch at the junction of the hard and soft palate (the speech-language pathologist should also palpate the palate to detect the presence of a notch that might be felt but not visualized),
    • a bluish line or translucent appearance down the midline of the palate (zona pellucida), and/or
    • a midline furrow or V-shaped elevation (or tenting) during phonation.
  • Note the factors that might provide clues about the etiology of velopharyngeal dysfunction (VPD; e.g., symmetry of movement of the soft palate during phonation).

Perceptual Evaluation of Speech

  • Precedes and determines the need for instrumental assessment
  • Includes classification of speech sound errors as well as assessment of resonance, nasal emission, and phonation
  • Includes judgments about the relationship between orofacial examination findings and perceived speech findings
  • Includes collection of speech samples, such as

Speech Sound Production

  • May include both standardized and nonstandardized assessments.
  • Differentiate speech sound error types across a variety of speech contexts. Error types include
    • obligatory articulation errors (errors that occur despite normal articulation placement and are caused by abnormal structures such as VPD or dental/occlusal abnormalities);
    • compensatory articulation errors (abnormal placement in response to abnormal structure), such as
      • backing to compensate for dental and/or occlusal interference with tongue tip movement and
      • pharyngeal placement (i.e., glottal stop or pharyngeal fricative) to compensate for lack of oral airflow as a result of velopharyngeal insufficiency;
    • velopharyngeal mislearning errors;
    • errors or distortions consistent with dysarthria or apraxia;
    • distortions secondary to nasal obstruction (e.g., denasalized /m, n/);
    • unusual articulations, including posterior and anterior nasal fricatives; and
    • developmental articulation errors and phonological errors.
  • Assess stimulability for compensatory errors and for developmental speech sound errors (if not age appropriate).
  • Assess speech intelligibility/comprehensibility and acceptability (Henningsson et al., 2008).

See ASHA’s Practice Portal page on Speech Sound Disorders – Articulation and Phonology.


  • 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 et al., 2006).
  • Assess for resonance deviations. Listen for the following:
    • Hypernasality
      • Excessive nasal resonance that occurs primarily on vowels and vocalic consonants. Hypernasality is the most defining speech feature of VPD.
    • Hyponasality
      • Reduction of nasal resonance that is perceived on nasal consonants when the nasal airway is partially blocked.
      • When present, assess the potential factors affecting nasal cavity obstruction (e.g., enlarged adenoids, restricted pharyngeal cavity space due to maxillary retrusion, shallow nasopharynx).
    • Mixed resonance
      • Elements of both hypernasality and hyponasality.
    • Cul-de-sac resonance
      • Sound is muffled and low in volume due to a blockage at the exit of one of the cavities of the vocal tract (nasal, oral, or pharyngeal; Kummer, 2020).
        • Oral cul-de-sac resonance: due to microsomia or small oral cavity and sounds like mumbling.
        • Nasal cul-de-sac resonance: due to stenotic nares. It affects nasal sounds and other sounds if there is also velopharyngeal insufficiency causing additional sound in the nasal cavity.
        • Pharyngeal cul-de-sac resonance: caused by enlarged tonsils.
  • Judge severity of abnormal resonance (see ACPA Normal and Hypernasal Speech and the Rochester Institute of Technology Training for listening samples).

Nasal Airflow

  • Second most defining speech feature associated with VPD.
  • Unwanted passage of air into the nasal cavity during the production of high-pressure oral consonants, including plosives, fricatives, and affricates. May range from visible to audible or turbulent.

Low-Tech Procedures for Assessment (Using Oral Pressure Consonants)

  • Used to confirm or verify what the clinician has heard.
  • Sometimes used to check for inaudible nasal emission.
  • Include the following:
    • Visual Procedures
      • Observe fogging on a mirror when placed under the nose during high-pressure consonant production.
      • Look for nasal grimace during speech that might coincide with nasal air emission.
      • Look for facial grimacing.
    • Tactile Procedures
      • Feel the sides of the nose for vibration that may accompany perceived hypernasality.
    • Auditory Procedures
      • Listen for audible or turbulent nasal air emission across multiple speaking contexts.
      • Alternately pinch and then release pressure on the nose (cul-de-sac test) while the child produces the same speech segment. Listen for a resonance and/or pressure shift when nostrils are closed. Velopharyngeal (VP) valve dysfunction is signaled by cul-de-sac resonance and improved oral pressure with the nose pinched.
      • Place one end of a straw or listening tube at nostril entrance and the other end to the examiner’s ear during production of oral consonants. Listen for sound/airflow exiting the nostril.
      • Determine whether nasal air emission is pervasive or phoneme specific. Use the production of oral pressure consonants—including stops, fricatives, and affricates—to assess nasal airflow.
      • Listen for audible nasal air emission across multiple speaking contexts.
      • Listen for the presence of weak pressure or no plosive quality on oral pressure consonants (obligatory to VPD).
      • Determine utterance length by having the child count beginning at 60 on one breath. Notice if phonation stops prematurely due to a loss of airflow through the nose.

Instrumental Evaluation of VP Function

  • Helps to explain perceptual speech findings with regard to VP function.
  • Assists with planning of surgical or prosthetic intervention to improve VP function.
  • Typically completed by a speech-language pathologist (SLP) affiliated with a cleft palate team.
  • Recommended when the perceptual speech findings identify a resonance disorder or nasal air emission.
  • Methods include the following:
    • Direct Observation via Imaging Studies
      • Multiview videofluoroscopy—provides a real-time X-ray video image of VP function during speech from three views (lateral, frontal, and base).
      • Nasopharyngoscopy—provides real-time visualization of VP function during connected speech using a flexible nasopharyngoscope inserted through the nasal cavity. Nasopharyngoscopy provides an en face view of the VP portal.
      • Lateral still cephalogram—provides a static X-ray of the palate at rest and during phonation of /i/, / u/, or sustained oral /s/.
      • Magnetic resonance imaging—using multiple image planes, provides information about VP structures and function.
    • Indirect Measures
      • Nasometry (acoustics)—measures nasalance, a ratio of acoustic energy from the speaker’s oral and nasal cavities. Nasalance is reported to have a modest correlation with listener ratings of severity because it picks up sound from both hypernasality and audible nasal emission but is consistent in measuring normal VP function. Nasometry is a measure of hypernasality.
      • Pressure-flow studies (aerodynamics)—measure oral and nasal pressure and nasal airflow as well as provide an estimation of VP orifice size during consonant production.


  • Assess for voice quality and signs of vocal fold pathology (e.g., hoarseness, breathiness).
  • May include
    • auditory-perceptual assessment;
    • instrumental assessment;
    • assessment of voice handicap; and
    • referral for ear, nose, and throat assessment.

For more information, see ASHA’s Practice Portal page on Voice Disorders.

Language (Spoken and Written)

  • Components will depend on the individual’s age and linguistic stage.
  • May include both standardized and nonstandardized assessments.

For more information, see ASHA’s resource on assessment tools, techniques, and data sources and the following ASHA Practice Portal pages:


  • Identification of
    • communication participation and activity (e.g., difficulty being understood, reduced participation in classroom activities),
    • facilitators (e.g., desire to interact with peers, supportive family and teachers), and
    • barriers (e.g., reluctance to initiate conversation with peers).

See Process Model for Assessing Speech, Resonance, and Language in Patients With Cleft and Craniofacial Anomalies [PDF] (Vallino-Napoli, 2004) for an example of an assessment decision-making flowchart. For audio and video examples of speech and resonance disorders associated with cleft palate, see Vallino et al. (2018).


Hall, M. J., Gibson, B. J., James, A., & Rodd, H. D. (2013). Children’s and adolescents’ perspectives on cleft lip and/or palate. The Cleft Palate–Craniofacial Journal, 50(2), e18–e26.

Henningsson, G., Kuehn, D. P., Sell, D., Sweeney, T., Trost-Cardamone, J. E., & Whitehill, T. L. (2008). Universal parameters for reporting speech outcomes in individuals with cleft palate. The Cleft Palate–Craniofacial Journal, 45(1), 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. (2020). Cleft palate and craniofacial conditions: A comprehensive guide to clinical management (4th ed.). Jones & Bartlett Learning.

Vallino, L. D., Ruscello, D. M., & Zajac, D. J. (2018). Cleft palate speech and resonance: An audio and video resource. Plural.

Vallino-Napoli, L. (2004). Assessing communication in cleft and craniofacial disorders: A process model for the practitioner. Perspectives on Speech Science and Orofacial Disorders, 14(2), 9–16.

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