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366 The Voice and Voice Therapy
contrast this production with recorded strident vocalizations using loop recording feedback
devices and following the various ear-training procedures.
3. Establishing new pitch. The strident voice is frequently accompanied by an inappropriately
high voice pitch. Efforts to lower the pitch level often produce a voice that sounds less
strident. We have found that a piano keyboard, an inexpensive electric keyboard, and the
CSL are valuable tools in helping patients find and establish a new pitch level or range that
produces a much less strident-sounding voice.
4. Counseling. Although it is difficult to explain problems of resonance to someone else,
sometimes such an explanation is essential if the patient is ever to develop any kind of selfawareness about the problem.
5. Glottal fry. The glottal fry produces two beneficial effects. First, the fundamental frequency
is somewhat lower following production of the glottal fry; second, the resonating cavity of
the laryngeal aditus is enlarged following the production of the glottal fry (especially on
ingressive glottal fry). The relaxation of the folds and the opening of the laryngeal aditus
effectively reduce strident vocal quality.
6. Hierarchy analysis. For the individual whose voice becomes strident whenever they are
tense, it is important to try to isolate those situations in which their nonstridency is
maintained.
7. Open mouth. Because stridency is generally the product of excessive constriction, oral
openness is an excellent way to counteract these tight, constrictive tendencies.
8. Relaxation. It is difficult to produce strident resonance under conditions of relaxation and
freedom from tension. Either general relaxation or a more specific relaxation of the vocal
tract is helpful in reducing oral-pharyngeal tightness.
9. Tongue protrusion /i/. This VFA increases the length and width of the pharynx (the whole
throat cavity).
10. Yawn-sigh. Because the yawn-sigh approach produces an openness and relaxation that is
completely the opposite of the tightness of pharyngeal constriction, it is perhaps the most
effective approach in this list for reducing stridency.
Improving Oral Resonance
Two problems of oral resonance are related to faulty tongue position: a thin type of resonance
produced by excessively anterior tongue carriage, and a cul-de-sac type produced by posterior
retraction of the tongue. The thin voice lacks adequate oral resonance, and its user sounds immature
and unsure of themself. This problem, which is somewhat common among both men and women,
is characterized by a generalized oral constriction with high, anterior carriage of the tongue and
only minimal lip-mandibular opening. The user of such a voice appears to be holding back psychologically, either withdrawing from interpersonal contact by demonstrating all the symptoms of
withdrawal or retreating psychologically to a more infantile level of behavior by demonstrating a
babylike vocal quality. The first type, the one who withdraws from interpersonal contact, employs
their thin resonance in certain situations, particularly when they feel most insecure; the second
type uses the thin voice, the babylike resonance, more intentionally, in situations in which they
want to appear cute, to get their own way, and so on.
CHAPTER 10 Resonance Disorders 367
The following VFAs (described in Chapter 7) have been useful in promoting a more natural
adult oral resonance:
1. Change of loudness. When the resonance problem is part of a general picture of
psychological withdrawal in particular situations, efforts to increase voice loudness are
appropriate for overall improvement of resonance.
2. Digital manipulation. This approach is especially helpful when the pitch of the voice is too
high or the quality is breathy and the larynx is higher than normal.
3. Establishing new pitch. The thin voice is perceived by listeners to be drastically lacking in
authority. Frequently, the pitch is too high. Efforts to lower the voice pitch often have a
positive effect on resonance.
4. Focus. In Chapter 7, we looked at tongue position and its influence on voice quality. The
babylike voice may disappear with greater posterior tongue carriage.
5. Glottal fry. The larger pharyngeal adjustment produced by glottal fry is generally helpful in
improving resonance.
6. Hierarchy analysis. Symptomatic voice therapy is based on the premise that it is often
possible to isolate particular situations in which we function poorly, with maladaptive
behavior, and other situations in which we function comparatively well. By isolating the
various situations and their modes of behavior, we can often introduce more effective
behavior into “bad” situations in place of the maladaptive behavior. For those individuals
who use a thin voice in specific situations, particularly during moments of tension, hierarchy
analysis may be a necessary preliminary step to eliminate the aberrant vocal quality.
7. Open mouth. The restrictive oral tendencies of a thin-voiced speaker may be effectively
reduced by developing greater oral openness.
8. Relaxation. If the thin vocal quality is highly situational and the obvious result of tension,
relaxation approaches may be helpful, particularly when used in combination with
hierarchy analysis.
9. Respiration training. Sometimes direct work on increasing voice loudness requires some
work increasing control of the airflow during expiration.
10. Visual feedback. Patients whose anterior resonance focus is related to situational tensions
may use feedback apparatuses to become aware of their varying states of tension. Feedback
is best used with relaxation and hierarchy analysis.
11. Yawn-sigh. The yawn-sigh approach is an excellent way of developing a more relaxed,
posterior tongue carriage.
Patients with a thin voice are often judged by listeners as immature, young, or lacking in
authority. We have provided successful voice therapy to several attorneys, managers, and executives
who suffered from thin voice quality, which was ineffective in their work.
The cul-de-sac voice is found in individuals from various etiologic groups: patients with oral
apraxia; children and adults with cerebral palsy, who may have a posterior focus to their resonance
added to their dysarthria; some patients with spastic or flaccid dysarthria, who have a pharyngeal
focus to their vocal resonance; and Deaf or severely hard of hearing children and adults. The culde-sac voice, regardless of its initial physical cause, is produced by the deep retraction of the tongue
368 The Voice and Voice Therapy
into the oral cavity and hypopharynx, sometimes touching the pharyngeal wall and sometimes
not. The body of the tongue literally obstructs the escaping airflow and the periodic sound waves
generated from the larynx below. Although such a voice is often found in individuals with neural
lesions who cannot control their muscles, and among Deaf children and adults, it is also produced
in certain situations by individuals for wholly functional reasons. Such posterior resonance is very
difficult to correct in patients who have muscle disorders related to various problems of innervation, particularly dysarthric patients. Resonance deviations in the Deaf may be changed somewhat
in voice therapy, as described in Chapter 8, by dealing with special problems. For individuals who
produce cul-de-sac resonance for purely functional reasons (whatever the cause), the following
VFAs from Chapter 7 are useful:
1. Auditory feedback. If, in the search for a better voice, the patient is able to produce a
more forward, oral-sounding one, this should be contrasted with their cul-de-sac voice by
listening to auditory feedback.
2. Focus. The forward focus in resonance required to place the voice in the facial mask makes
the approach a useful one for patients with a cul-de-sac focus. High front vowels and
front-of-the-mouth consonants are particularly good practice sounds to use with the focus
approach.
3. Glottal fry. The production of the glottal fry opens the pharynx and the laryngeal aditus,
thus enlarging the resonance cavity and adding to the openness of the whole vocal tract.
The whole pharynx is relaxed, eliminating the cul-de-sac resonance.
4. Hierarchy analysis. If cul-de-sac resonance occurs only in particular situations, perhaps
when the individual is tense and under stress, the hierarchy approach may be useful. If the
individual can produce good oral resonance in low-stress situations, they should practice
using the same resonance at levels of increasing stress, on up the hierarchy.
5. Nasal-glide stimulation. This approach helps to get a forward placement of the tongue, and
the sound and can be used in conjunction with focus.
6. Relaxation. Posterior tongue retraction during moments of stress is often a learned response
to tension. The patient who can learn a more relaxed positioning of the overall vocal tract
may be able to reduce excessive tongue retraction.
7. Tongue protrusion /i/. With this approach, the tongue is extended outside the mouth and
the pitch is elevated; thus, the base of the tongue is pulled forward and out of the oral
pharynx, which is emphasized with the /i/ vowel. This eliminates the retracted tongue
position that produces the back quality.
PluralPlus
Self-Check
10–5
8. Visual feedback. For some patients, posterior focus of voice resonance may be situationally
related to tension. Feedback is often useful for helping these patients monitor their varying
tension states.
Summary
Resonance disorders often result from physical problems of structure or function at various sites
within the speech tract. Primary efforts must be given to identifying any structural abnormalities
and correcting these problems by dental, medical, or surgical intervention. SLPs play an impor-
CHAPTER 10 Resonance Disorders 369
tant role in the early evaluation and diagnosis of a resonance problem, as well as in providing
needed voice therapy to correct the problem. Voice therapy is often necessary and is very effective
following surgical and dental prosthetic treatments. For both organic and functional resonance
problems, specific VFAs are listed throughout this chapter to help patients develop better nasal
and oral resonance.
GUIDED READING
Read the following articles:
Kummer, A. W. (2023). Normal speech and language and the management of speech disorders
in patients with clefts. In P. R. Shetye & T. L. Gibson (Eds.), Cleft and craniofacial ortho-
dontics (Chap. 19, pp. 236–248). Wiley. https://doi.org/10.1002/9781119778387.ch19
Moren, S., Mani, M., Lilian, S., Lindestad, P. A., & Holmstrom, M. (2018). Speech in adults
treated for unilateral cleft lip and palate: Long-term follow-up after one- or two-stage
palate repair. Cleft Palate Craniofacial Journal, 54(6), 639–649.
Describe four ways in which the information reported in the articles might influence your
clinical practice.
PREPARING FOR THE PRAXIS
Directions: Read the case studies and answer the five questions that follow.
Leonardo is a second-grade student referred to you by his homeroom teacher, who asks you to
look into his “strange vocal quality” that “comes and goes.” The teacher mentions that he sounds
“nasal.” A quick screen using the key phonemes described in this chapter reveals that Leonardo
produces the /b/, /d/, and /g/ in place of the /m/, /n/, and /
1. This type of resonance disorder is most likely:
A. Hyponasality
B. Hypernasality
C. Cul-de-sac
D. Assimilative nasality
2. Other signs that Leonardo might present with are:
A. Rhinorrhea
B. Otitis media
C. A history of allergies
D. All of these
ŋ
/.
370 The Voice and Voice Therapy
Clara is a third-grade transfer student who is referred to you with teacher observations of a
“nasal voice.” Clara has moved from three different school districts in a year and a half. There
is no medical history available at the moment, but you go ahead and initiate a brief screen.
You inspect the oral cavity, making clinical observations of the lips, tongue, teeth, and hard and
soft palates, among other structures. You ask Clara to produce a series of short /a/ productions to
assess the movement of the velum.
3. Based on these observations, you can:
A. Observe velar movement through the oral cavity.
B. Diagnose a velopharyngeal disorder.
C. Begin therapy.
D. Determine the need for a pharyngoplasty.
4. You ask Clara to count from 62 to 66. As she does so, you place a fogging mirror
beneath the nares. The mirror fogs throughout the entire production, and you
perceive moderate nasal resonance and nasal air emission throughout. This type of
resonance disorder is most likely:
A. Hypernasality
B. Due to an obstruction in the nasal cavity
C. Isolated to the velopharynx
D. Assimilative nasality
5. The task of counting from 62 to 66 was used because it:
A. Is composed of high-pressure phonemes
B. Is composed of low-pressure phonemes
C. Gives a quick look at articulation and the acquisition of any compensatory errors
D. Both A and C
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