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346 The Voice and Voice Therapy
vowels in isolation, and their sentences (some with only oral phonemes and some loaded with nasal
phonemes). Loading sentences with nasal phonemes is helpful for making judgments of hyponasal
speech. By carefully structuring the test samples, rather than relying on conversation, one can
control the phonemes used and their order, which is helpful in detecting assimilated nasality. The
recorded sample also allows the clinician repeated playback.
We found that asking patients to repeat or read aloud passages that are totally free of nasal
consonants, such as “Betty takes Bob to the show,” or passages that are loaded with nasal consonants, such as “Many men in the moon,” helps us differentiate nasal resonance disorders from one
another. It is important to note that hypernasality occurs only on vowels, semivowels, and voiced
consonants. Phrases loaded with nasal consonants are used only to demonstrate hyponasality. The
absence of normal nasal resonance on these nasally loaded phrases is diagnostic of hyponasality. We
also found that if we use the following simple screening procedures, we get a good, quick clinical
classification of the type of resonance disorder present. These quick tests are simple and require
no instruments to perform.
We begin the screening by having the patient say these two sentences while gently pinching the
nares closed: “My name means money” and “Mary made lemon jam.” If these sounds are plugged
both when the nares are pinched and when the nares are released, the problem is hyponasality.
In other words, if there is no difference between the nose-held and nose-released conditions, the
problem is consistent with hyponasality. If there is a big difference between the nose-held and
nose-released conditions, then the problem is likely hypernasality.
Another simple clinical technique is called the snap release /s/. We have the patient sustain a
sustained /s/ while the nares are pinched closed and then quickly released. If a snap is heard on
releasing the nares, this means the VP mechanism is partially open and the problem is probably
hypernasality. The snap is actually nasal air emission, but it gives a clue of the status of the VP
mechanism. While hypernasality is a phenomenon of voiced sounds only, this technique uses a
nonvoiced sound /s/ to test the adequacy of closure of the VP mechanism. This is done because
there is more intraoral breath pressure required for a voiceless consonant, /s/, than a voiced consonant, and this greater pressure is a better test of the adequacy of the VP mechanism.
Next, we have the patient say, “This horse eats grass” and “I see the teacher at church.” If we
hear any “snorting” back in the pharynx, we can assume that it is probably due to inadequate
closure of the VP port and that the problem with this speaker’s voice is hypernasality. We next
ask the patient to say, “Maybe baby, maybe baby.” If there is no difference between the /m/ in
maybe and the /b/ in baby, and both sound like maybe, the problem is hypernasality; however,
if both words sound like baby, the problem is hyponasality. Finally, we ask the patient to sustain
the /i/ and the /u/ vowels while we gently flutter the nose (nasal flutter test) by rapidly pinching
and releasing the nares with the thumb and forefinger. If we hear a pulsing change in the acoustic
signal, the problem is likely hypernasality.
Assessing Voice
SLPs in cleft palate and craniofacial clinics need to understand the etiologies of pediatric voice
disorders, their connection to cleft lip, palate, and craniofacial anomalies, and resonance disorders.
Overlapping risk factors exist, emphasizing the need for SLPs to recognize voice disorders and
refer for specialized evaluation and treatment (Moren et al., 2018). The SLP must not only make
CHAPTER 10 Resonance Disorders 347
judgments about resonance, but the SLP must also listen closely to and make observations about
vocal quality for problems of hoarseness, loudness, and breathiness.
A number of investigations into the etiology of dysphonia associated with cleft lip and palate
suggest that efforts to reduce air leakage to the nasal cavity could lead to severe vocal fold hyperfunction in both children and adults with cleft palate (Aydınlı et al., 2016; Braden, 2022; Martins
et al., 2016). Fujiki and Thibeault (2023) assessed laryngeal pathology prevalence in children with
cleft palate, using nasoendoscopy, and explored its correlation with patient demographics and
speech outcomes. Their study was conducted at an outpatient pediatric clinic, and it involved
215 children over 11 years. A 22% prevalence of laryngeal pathology was reported, with increased
risk linked to age and prior palatal repair but inversely related to severe hypernasal resonance.
The study underscores the importance of thorough laryngeal evaluation in this group, suggesting
further research to understand the risk factors.
Check Your Knowledge
1. Which utterances can you use to help differentiate hypernasality
from hyponasality?
2. What is the likelihood that your client with velopharyngeal dysfunction might be dysphonic?
Simple Clinical Instrumental Assessment
In the evaluation of nasal air emission and hypernasality, we recommend practical and costeffective tools for both assessment and therapeutic feedback. The first tool is a fogging mirror
placed under the nose during speech to visually confirm nasal air escape, indicated by fogging.
The patient should say phrases like “Buy baby a bib,” and the mirror should remain clear during
speech if the VP mechanism is functioning correctly.
A listening tube, or an “octopus,” is another useful device. Constructed from nasal olives
attached to the ends of rubber tubing, this device allows clinicians to hear nasal emissions. Even a
simple straw, with one end at the patient’s nose and the other near the clinician’s ear, is an efficient
way to detect subtle signs of hypernasality. Furthermore, SLPs can feel for vibrations on the side
of the nose to sense hypernasality. This tactile method can detect nasal air escape.
These tools are not only valuable for diagnosing resonance disorders but also serve as feedback
mechanisms during therapy, aiding in the rehabilitation of individuals with hypernasality, whether
or not it is accompanied by excessive nasal air emission.
Stimulability Testing
Originally, stimulability testing was designed for use with problems of articulation; however, it
is also effective for use with problems of voice. The basic purpose of stimulability testing, as first
described by Milisen (1957) and more recently, Derakhshandeh and colleagues (2016), was to see
how well the patient can correctly produce a sound made in error when the patient is repeatedly
348 The Voice and Voice Therapy
presented with the correct sound through both auditory and visual stimuli. One way of distinguishing between true problems of VP insufficiency (the mechanism is incapable of adequate
closure) and VP inadequacy (the mechanism has the capability of closure) is to determine whether
the patient can produce oral resonance under stimulability conditions (Morris & Smith, 1962).
Obviously, the patient’s success in producing oral resonance is a strong indication that VP closure
is possible. Shelton and colleagues (1968) have observed:
If repeated stimulation consistently results in consonant productions which are distorted
by nasal emission and vowels which are unpleasantly nasal, the inference can be drawn, at
least tentatively, that the individual is not able to change his speaking behavior because of
VP incompetence. (p. 236)
Another simple stimulability test is to elevate the patient’s velum with a tongue depressor
while fluttering the nose during the patient’s production of a sustained /i/ vowel. Next, remove the
tongue depressor and repeat the process, listening for a difference in resonance. If the difference
is dramatic, the patient will likely not be able to benefit from voice–speech therapy alone but will
require a palatal lift, speech obturator, or surgical management.
Articulation Testing
Correct articulation is an essential sign of proper VP function. When air escapes through the
nose during speech, this is known as nasal emission and is often observed in individuals with VP
dysfunction (VPD). This can happen even if the person’s articulation seems accurate, as in the
correct tongue, lip, and teeth positioning for speech sounds. However, if there is an issue with
the VP mechanism, the oral pressure that is supposed to build for certain sounds like “p,” “t,” or
“s,” may escape through the nose, leading to nasal emission. Distinguishing nasal emission caused
by VP inadequacy from other articulation errors is crucial. This distinction helps voice clinicians
identify whether the speech error is due to incorrect articulator positioning or a structural issue
with the VP closure. Recognizing the difference is key to planning effective therapy for those with
resonance disorders.
An articulation test for assessing competency of VP closure is found in the 43 special test items
from the Templin–Darley Tests of Articulation (Templin & Darley, 1980), known as the Iowa
Pressure Articulation Test. Although dated, this subtest of the Templin–Darley test is particularly
sensitive for identifying the presence of nasal emission during the production of certain consonants. However, any standardized articulation test is useful for determining those phonemes that
are distorted because of inadequate VP closure. The clinician must closely assess the identified
errors to determine if lingual placements are adequate to make the target phoneme correctly. Many
younger children with VP problems exhibit sound substitutions and omission errors (compensatory articulation) in addition to the nasal emission and nasal snort distortions. Older children
and adults with nasal emission problems may well have correct articulatory lingual placements,
and their distortions are products of posterior nasal escape of the airstream. Following successful
pharyngeal flap surgery or the proper fitting of a speech appliance, nasal emission and compensatory errors sometimes continue until they are addressed through speech remediation. This is why
therapy aimed at correct place of articulation is usually appropriate for children with cleft palate.
Intervention strategies for compensatory articulation and other speech disturbances in children
CHAPTER 10 Resonance Disorders 349
with cleft palate craniofacial (CPCF) disorders have been reported by Pamplona and colleagues
(2017), Kaiser and colleagues (2017), Peterson-Falzone and colleagues (2017), Kummer (2014),
among others.
The so-called pressure consonants provide the best test of the adequacy of the VP mechanism.
ʃ
These consonants — /p/, /b/, /k/, /g/, /t/, /d/, /f/, /v/, /s/, /z/, /
/, /ʒ/, /tʃ/, /dʒ/, /θ/, and /ð/ — should
be included in any testing of the adequacy of the VP port mechanism because these sounds require
the greatest degree of VP closure and the greatest intraoral air pressure (Van Demark, 1970). On
the other end of the spectrum, hyponasality, in its purest and most overt form, would be exhibited
on an articulation test with these oral substitutions for the nasal phonemes: /b/ → /m/, /d/ → /n/,
ŋ
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and /g/ → /
dabe beads buddy.” Assimilative nasality would be observable only for vowels or voiced consonants
in words containing nasal phonemes.
/. The sentence “My name means money” would be produced, for example, as “By
Laboratory Instrumentation
Many instruments available today can help the clinician evaluate various aspects of nasal resonance. These instruments can also be valuable in the process of managing the patient with a
nasalization problem. We consider separately instruments that provide aerodynamic data, acoustic
information, radiographic visualization, and visual information.
Aerodynamic Instruments
Pressure transducers and pneumotachometers are vital tools in speech pathology for measuring
simultaneous nasal and oral air pressures and flows during speech. These instruments enable
clinicians to evaluate the function of the VP mechanism and detect any abnormal nasal emissions during speech. As mentioned in Chapter 6, the Phonatory Aerodynamic System (PAS)
(PENTAX Medical, Montvale, New Jersey) is particularly valuable for these measurements. It
can be used with either a tube or face mask and provides concurrent airflow and pressure data
from both the nose and mouth. These data are crucial for assessing individuals with resonance
disorders, as typical speakers show little to no nasal emission for most sounds, while those with
nasality issues will exhibit abnormal nasal flow patterns. There are normative data for the PAS,
which can help clinicians make diagnostic and treatment decisions (Weinrich et al., 2013; Zraick
et al., 2012). Aerodynamic testing with these devices informs the clinician about any unintended
nasal air leakage, which indicates VP insufficiency (Schaeffer, 2024). Manometers are another
option; they measure the pressure of the airstream, which can be indicative of the speaker’s ability
to generate the necessary pressure for speech without measuring resonance directly. These assessments, particularly the water manometer, are practical and cost-effective methods for gauging
respiratory pressure essential for speech production.
Nasometry and Nasalance
As shown in Figure 10–1, The Nasometer Model 6500 (PENTAX Medical, Montvale, New
Jersey) is a technologically advanced instrument that serves as an evolutionary step from Fletcher’s
initial Tonar II design (1978). It is engineered to quantitatively evaluate the balance between oral
350 The Voice and Voice Therapy
F IGU RE 10 1. The Nasometer Model 6500 in clinical use. Used with the
permission of Pentax Medical.
and nasal speech components. Utilizing a dual-microphone setup, the Nasometer distinguishes
between oral and nasal sounds. These microphones are strategically positioned on each side of a
specially designed nasal separator that is comfortably secured to the user by a headgear. The system
works by digitizing and filtering the sound, allowing for the calculation of nasalance, a term that
refers to the proportion of nasal sound to overall speech. An increase in this value suggests greater
nasal resonance. Beyond its measurement functions, the Nasometer Model 6500 offers real-time
visual feedback through a display, which can be instrumental for patients working on modifying
their oral–nasal sound ratio during therapy sessions. The NasalView (Tiger DRS, Inc., Seattle,
Washington) and the OroNasal System (Glottal Enterprises, Inc.) are additional microcomputerbased systems that yield scores for oronasal resonance.
Three passages are commonly used to obtain nasalance scores: the Zoo Passage, which contains
no nasal phonemes; the Rainbow Passage, which contains 11% nasal phonemes; and the Nasal
Sentences, which contain approximately 35% nasal phonemes. Each of these passages can be easily
accessed at the ASHA website (https://www.asha.org). Fletcher and colleagues (1989) obtained
nasalance scores from 117 children with no history of resonance disorders. The mean nasalance
scores for each stimulus were significantly different from the others, indicating that nasalance scores
are sensitive to the proportion of nasal phonemes in each speech sample. Additional assessments
that produce nasalance scores are the MacKay-Kummer SNAP Test-R, which features reading
CHAPTER 10 Resonance Disorders 351
passages and picture stimuli (Alfwaresse et al., 2022). The Nasality Severity Index (NSI) (Van Lierde
et al., 2007) is a multiparametric approach in the identification of hypernasality that consists of
a combination of three acoustic parameters, including two nasalance measures as captured by the
Nasometer, and low tone to high tone ratio. Bettens and colleagues (2016) compared perceptual
measurements of resonance with the NSI for 42 patients with cleft lip and palate and 50 children
without resonance disorders. Findings suggested that the NSI discriminates among individuals with
cleft lip and palate and controls with high sensitivity, specificity, and validity.
Spectrography
It has been demonstrated spectrographically that speakers with increased nasalization demonstrate
more prominent third formants with an increase in formant bandwidth, accompanied by a rise
in fundamental frequency. It is doubtful that the visual printout provided by the spectrograph
can provide the clinician with any more information about the type of nasality they hear than
does listening carefully to the same samples. This is not surprising because nasality is a perceptual
phenomenon. The spectrograph and the Computerized Speech Lab (CSL) (PENTAX Medical,
Montvale, New Jersey) can help identify the aperiodic noise of nasal emission, but differentiating
between spectrograms of speakers with hypernasality and those with hyponasality or assimilative
nasality is most difficult and not clinically practical. As clinicians learn to use the spectral analyses
provided by the spectrograph and CSL, however, these instruments may well become most useful
tools for studying various parameters of nasality. (The CSL was discussed in Chapter 6.)
Imaging Studies
Visual assessment of the VP mechanism is multidisciplinary and constantly evolving with the
introduction of new instrumentation or new procedures using existing instrumentation. Visual
assessment of the VP mechanism can include radiography, multiview videofluoroscopy, nasopharyngoscopy (endoscopy), and more recently, MRI. The reader is encouraged to explore these
approaches in greater detail by referring to Shadi and colleagues (2022), Sitzman and colleagues
(2024), and Sullivan and colleagues (2022). In this section, we focus on endoscopic evaluation of
the VP mechanism.
Endoscopy
Endoscopy entails direct visualization of the velopharynx by endoscope to evaluate for VP closure
patterns or a VP gap while the individual is performing specific phonatory tasks (Sagar & Nimkin,
2014). This direct visualization offers many advantages in making treatment decisions. The oral
endoscope has also been a useful instrument for determining the degree and type of VP closure,
as shown in Figure 10–2. The body of the oral endoscope is extended above the tongue within
the oral cavity so that the lighted tip and viewing window lie just below the uvula and within the
oropharyngeal opening. By turning the viewing window up toward the VP area, the velum, the
lateral pharyngeal walls, and the posterior pharynx may be visualized. Two views of varying degrees
of VP closure in the same subject are shown in Figure 10–2. One important disadvantage of the
oral endoscope is that one can observe only vowel or limited consonant and vowel combinations
352 The Voice and Voice Therapy
A B
F IGU RE 10 2 . Velopharyngeal closure. This oral videoendoscopic view of velopharyngeal closure
demonstrates two degrees of closure in a sequence, from an open velopharyngeal mechanism in
(A) through the bulging of Passavant’s pad with posterior and lateral pharyngeal wall movement
and the velar movement in (B).
such as /pa/ or /ba/. This is due to the unnatural introduction of the oral endoscope into the oral
cavity and its effect on articulation and connected speech (McFarlane, 1990).
For many of us who work in the area of cleft palate or who work with those who have VP
inadequacy due to structural defects (such as postcancer surgery) or neurological defect (such as
one of the dysarthria subtypes discussed in Chapter 5), the use of videonasoendoscopy of the VP
mechanism has become the gold standard. For example, with a nasal fiberoptic endoscope, which
advances a small flexible scope through the nasal cavity and down into the pharynx, the clinician
can observe VP closure (during connected speech) from above the closure site, and the dynamics
of VP function can be studied. The primary advantage of the flexible endoscope is that it is not
invasive to the oral cavity and consequently does not impede tongue, lip, or jaw movements
during dynamic articulation (a limitation of the oral endoscope). The oral and nasal endoscopic
probes are effective instruments for assessing VP competence in patients with nasal resonance
problems because they offer direct observation of velar length and movement, degree of lateral
and posterior pharyngeal wall movement, and the type of VP closure the patient is using. Perhaps
most important, this examination allows the clinician and the patient to see the various types and
degrees of VP closure during a variety of phonetic contexts.
Watterson and McFarlane (1990) introduced in detail the use of transnasal videoendoscopy
of the VP port mechanism. They discuss the use of sustained vowels, sustained consonants, single
words and sentences, and phrases as speech stimuli in speech testing for VP competency. The use
of high vowels such as /i/ and /u/ as well as stops (/p/, /k/, /t/), fricatives, and affricates allows
the examiner to make important statements about the ability of the VP mechanism to manage
complex speech tasks successfully. The information gained by using such stimuli guides therapy
CHAPTER 10 Resonance Disorders 353
and management decisions. For example, it is important to know whether the patient consistently
experiences nasal air escape on a particular phoneme, such as /s/; if there is a breakdown of VP
function only at the phrase level; or if the particular phoneme, such as /s/, occurs in the context
of a blend.
As McFarlane (1990) and Boone and McFarlane (1994) have shown, even children can be
examined with nasoendoscopy without the use of any topical anesthetics. Figure 10–3 shows a
patient being examined with rigid endoscopy, and Figure 10–4 shows a child being examined with
nasoendoscopy, both without the aid of topical anesthesia. Indeed, in a prospective, double-blind
study, Leder and colleagues (1997) concluded that “speech-language pathologists can perform
independent and comfortable transnasal endoscopy without administration of any substance to
the nasal mucosa” (p. 1352).
Distinct variations in patterns of VP closure have been demonstrated by various researchers
(Jordan et al., 2017; Mason et al., 2016; Ozkan et al., 2022). Some subjects have only velar
movement without associated pharyngeal wall movement, some subjects primarily have lateral
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and posterior pharyngeal wall constriction, and some achieve closure by a combination of velar
and pharyngeal movements. Watterson and McFarlane (1990) described five useful classes of VP
function and provide a basis for making recommendations for clinical treatment.
F IGU RE 10 3. Oral videoendoscopy. This patient is examined by oral videoendos-
copy. Children and adults are routinely evaluated in this manner without the use
of any topical anesthetic.
354 The Voice and Voice Therapy
F IGU RE 10 4. Nasoendoscopy of a child with a voice disorder.
Treatment of Nasal Resonance Disorders
Hypernasality
The presence of excessive nasal resonance (hypernasality) is relatively dependent on the judgment
of the listener. That is, some languages and regional dialects require heavy nasal resonance and
therefore consider pronounced nasalization of vowels to be normal. Others, however, such as
standard U.S. English, tolerate little nasal resonance beyond the three nasal consonants. The
judgment of hypernasality, then, is as dependent on the speech-language milieu of the speaker
and their listeners as it is on the actual performance of the speaker.
The speaker who is judged to be hypernasal increases the nasalization of their vowels and
voiced consonants by failing to close their VP port. This failure to close the VP opening may
be related to neurological or structural-organic defects, or it may have a functional etiology.
Hypernasality frequently accompanies unrepaired cleft palate and the accompanying short palate
(inadequate tissue). Among other causes of the disorder are surgical trauma (e.g., postadenoidectomy), accidental injury to the soft palate, and impaired innervation of the soft palate as a result
of poliomyelitis or some other form of upper or lower motor neuron disease or traumatic brain
injury (incompetent movement). Sometimes temporary hypernasality may follow surgical removal
of the adenoids and tonsils as the patient attempts to minimize the pain by not moving their VP
CHAPTER 10 Resonance Disorders 355
mechanism. But when hypernasality persists for 2 or 3 months or more following adenoidectomy
or tonsillectomy, the adequacy of the VP mechanism must be suspected and evaluated.
Some people speak with hypernasal resonance for purely functional reasons, perhaps to
maintain a lingering internal model of a previously acceptable form of resonance, or perhaps
to imitate the voice of someone they admire (such as a famous political figure or performer).
Although the majority of people with hypernasal voices probably have some structural or neurological basis for their lack of VP competence, the ease of imitating a hypernasal voice tells us
that it could be relatively easy to become hypernasal with perfectly adequate and normal VP
anatomy and physiology. Hypernasality is one voice problem in which the distinction must be
made between organic and functional causes because the treatment recommended is quite specific
to the diagnosis.
If there are any indications of physical inadequacy of the VP closure, the primary role of the
SLP is to refer the patient to a specialist who can provide the needed physical management: a
plastic surgeon, say, or a prosthodontist. The SLP makes the determination of the mechanism’s
adequacy for speech purposes, and the patient and other professionals together determine the best
corrective approach. If surgery is selected, the SLP shares the results of the speech–voice evaluation
to aid with the selection of an appropriate surgical procedure. Postsurgically, the SLP evaluates the
repaired VP mechanism to determine its adequacy for speech-language production.
If dental appliances are to be selected, the SLP suggests the type of appliance, lift, or prosthesis with a bulb, and assists with the design and fitting of the appliance. If a prosthetic form
of management is used, then the SLP is involved in the initial fabrication and fitting of the velar
lift or obturator. Subsequent modifications of these devices are directed by the SLP based on the
results of their speech testing and the patient’s response to clinical speech stimulation.
There is no evidence that voice therapy to improve resonance has any positive effect in the
presence of physical inadequacy. In fact, there is some indication that voice therapy to improve
the oral resonance of patients with palatal insufficiency (those who lack the physical equipment to produce closure) usually fails; in addition, such attempts are usually interpreted by
the patient as their own fault — as a defeat indicating low personal worth — and thus take an
obvious toll on the patient’s self-image. An example of the ineffectiveness of speech therapy in
the presence of a severe inadequacy of VP closure is provided by this case of a teenage girl with
VP dysfunction who had received speech therapy for both articulation and resonance for a period
of 7 years:
Jasmine, age 14 years, had received 7 years of group and individual speech therapy in the
public schools and in a community speech and hearing clinic for “a severe articulation
defect characterized by sibilant distortion, and for a severely nasal voice.” Jasmine’s
mother became upset because of Jasmine’s continued lack of progress and her tendency
to withdraw from social contact with her peers, which, the mother felt, was related
to her embarrassment over her continued poor speech. Jasmine was evaluated by a
comprehensive cleft palate team, which, after reviewing her history, found that her nasality
dated from a severe bout of influenza when she was 6 years old. The influenza had been
followed immediately by a deterioration of speech. Subsequent speech therapy records
were incomplete, although the mother reported that the therapy had included extensive