Short Course 32: Part 3:

Treatment of Resonance
Disorder
Lynn Marty Grames, MA, CCC-SLP
St. Louis Childrens Hospital
Cleft Palate and Craniofacial Institute

Video Examples of Resonance

Disorder

Video Examples of Resonance

Disorder

Video Examples of Resonance

Disorder

Video Examples of Resonance

Disorder

Video Examples of Resonance

Disorder

Objectives
Identify the type of resonance disorder
Identify possible causes of resonance
disorder
Describe which types can be treated with
therapy, and which with
medical/surgical/dental management
Identify articulations that enhance or mimic
resonance disorder

What is resonance?
Phonetics . a. amplification of the range of
audibility of any source of speech sounds,
especially of phonation, by various couplings of
the cavities of the mouth, nose, sinuses, larynx,
pharynx, and upper thorax, and, to some extent,
by the skeletal structure of the head and upper
chest.
b. the distribution of amplitudes among
interrelated cavities in the head, chest, and
throat that are characteristic for a particular
speech sound and relatively independent of
variations in pitch.

The Resonance Subsystem

What is a resonance disorder?

Difference in the amplified phonation caused
by structural anomaly or by inefficient or
ineffective use of the structures of the
supraglottal airway

Resonance Disorder

Hyponasality
Hypernasality
Mixed hyper/hyponasality
Cul-de-sac resonance
Decreased oral resonance
Potato in the mouth?!?

Hyponasality
Insufficient sound amplification through
the nasal cavities
Consonants affected will include [m,n,]
May sound like [b,d,g]
May not be affected to the same degree

Mouth breathing and nasal congestion

may be present.

Hyponasal resonance

How to test for hyponasality?

Nasal consonant loads

Words:

Mom
Money
Hammer
Noon
Nine
Banana
Hanger
Hamper

Phrases:
Mama made
lemonade
No more money
My mom made jam
Jane came in
The phone rang again
Banana nut muffin
The singer sang a
song

Also evaluate:
Nasal airway patency
Lips closed: breathe in, breathe out
Look for mouth breathing at rest
Intraoral Exam
Is the adenoid visible on phonation?
Stimulability for nasal consonants

Nasal Airway
is not Patent:
Can the child
clear it?

Yes.
Retest.

No.
Consider cause,
Refer.

Resonance
improves: may
have cold
or allergies

Resonance
does not improve,
test for stimulability

Somewhat.
Consider causes,
Refer.

If the nasal airway is patent, the

hyponasality may be functional
Teach nasal consonants!

Other questions to ask:

Is breathing noisy some or all of the time?
Does the child snore at night?
Do parents notice gasping, sweating,
restlessness during sleep?
Is the child frequently sleepy or
hyperactive?
Does the child have difficulty concentrating
at school?

Nasal Airway Obstruction

Causes:

Associated issues:

Enlarged adenoid

Allergies
Colds

Nasal septal deformity

Turbinate hypertrophy
Cleft nasal deformity
Choanal stenosis
Obstructive velopharyngeal

Snoring
Obstructive sleep
apnea
Lip closure for feeding

surgery

Nasal airway obstruction

requires medical referral
Pediatrician, ENT,
Allergist, or Cleft Palate Team

Always have parents sign a

release allowing you to
communicate with the care
provider
Contact provider with your
findings and questions. Stay in
touch!

Hypernasality
Results from excessive or
inappropriate airflow into the nose
during speech.

Manifestations of Excessive or
Inappropriate nasal airflow

Hypernasal resonance (vowels)

Weakened oral pressure consonants
Reduced plosion and stridency
Nasal emission
Nasal turbulence
Nasal grimacing

Hypernasality with nasal emission

and grimacing

Manifestations of Nasal
Fricative/Stop Production

Hypernasal resonance
Weakened oral pressure consonants
Reduced plosion and stridency
Nasal emission
Nasal turbulence
Nasal grimacing

Hypernasality, nasal turbulence,

nasal stops and fricatives

How do we tell the difference?

Careful evaluation!
Resonance vs. Articulation Quick
Check
Email lynnmg@bjc.org

Phrases with oral consonant loads

Pop a bubble
Buy a puppy
Purple paper
Pack your backpack
Daddy did it
I did it too
Its too tight
Go get it
Cookie and cake

Sissy saw it
Zippers are easy
Shoes and socks
You should wash
Check your watch
Jump for joy
Four or five
Four fire fighters
There they are

What if you find.

Improved plosion
Improved resonance
Cul-de-sac resonance
Improved stridency
Child sounds better!

This child needs a

complete
velopharyngeal
evaluation.

What if you find.

Stops and plosives
sound good
Some or all fricatives
are stops, or a
posterior click
Child seems like he is
blowing his brains out
on some fricatives

This child has an

articulation disorder
that you will need to
treat.

Video Examples of Resonance

Disorder

What if you find

Not much improves
Plosives sound off (or
odd)
Fricatives sound off
(or odd)
Resonance doesnt
really change much
with the nose plugged

This child may have

VPD, but may need
some articulation
therapy first in order to
prepare for a valid
exam.

 Pharyngeal stops

[ ]
Voiceless [ ]
Voiced

Pharyngeal
Fricatives

[ ]
Voiceless [ ]
Voiced

Pay careful attention to what

you learn about articulation
from the exam.

Remember that
velopharyngeal dysfunction
affects resonance..
If an articulation does not change
with the nose plugged, changing
VP function will not change the
articulation.

Whether or not true

hypernasality is present.
If stop/plosive consonants are not
articulated correctly, teach the correct
articulation.
If fricatives or affricates are not articulated
correctly, teach the appropriate
articulation.

Specific Tx Techniques are needed

Use a motor learning
approach
Do not use oral motor
exercises
Do not worry about
sensory stim
Use speech to teach
speech
You may need to plug
the nose!

Peterson-Falzone,
Trost-Cardamone,
Karnell and HardinJones:
A Clinicians Guide to
Treating Cleft Palate
Speech

If the velopharynx is truly

dysfunctional, can I still treat
any articulation errors I
discover?

Yes! And you should!

Video Examples of Resonance

Disorder

What do I do if the velopharynx

is dysfunctional?
Refer to a cleft palate center that performs
velopharyngeal diagnostic exams
In most cases a referral to a community
ENT physician is not helpful.

Most importantly
Have parents sign a release for you to
communicate with the treating medical
team.
Send a report with your concerns and test
results.
Stay in touch!
Dont be afraid to ask questions!

What will be done?

Full diagnostic exam
Perceptual speech exam
Medical history

Various imaging or instrumental

assessments:
Velopharyngeal endoscopy
Speech Videofluoroscopy
Nasometry
Pressure-flow studies

Physical management
Furlow Double-opposing z-plasty

Physical management
Sphincter pharyngoplasty

Physical Management
Pharyngeal Flap

Intermittent or neurologically
based hypernasality

Video Examples of Resonance

Disorder

Intermittent or neurologically
based hypernasality
Evaluate influence of rate and respiratory
drive on speech resonance
If concerns are identified, try to treat those
concerns
Evaluate results, and consider referral for
diagnostic studies if needed.
ALWAYS refer if the symptoms are new!

Treatment options?
Some centers may
choose a trial with a
prosthesis.
Reversible
Costly (time and $)
Insurance may not
cover
Motor relearning
phase may be
problematic

Is this necessary?

The child who becomes

hypernasal after adenotonsil
surgery
Be patientmany centers wait 6
weeks to 6 months to evaluate

Should I buy some special

equipment?
See-scape?
Nasometer?
Flexible tubing?

Cultivate a relationship with a

cleft palate team SLP
Dont be afraid to ask questions.
Collaboration can be the best
technique with hard-to-treat kids.

Questions?
Thank you for attending our short
course. Please be sure to
complete your online evaluation
forms for your CEUs.