Hypernasality is caused by too much airflow through the nasal cavity when speaking. This makes non-nasal sounds sound nasal.
Speech therapy can treat some cases of hypernasality—and make helpful referrals for the rest.
In this article, you’ll learn:
- How to assess hypernasality
- When to refer out (and who needs a palatal lift)
- 6 hypernasal speech treatment ideas
Plus, watch a how-to video.
For print-and-go Voice & Resonance PDFs, visit our shop!
What Causes Hypernasal Speech?
Hypernasal speech is caused by 1) structural, 2) neuromotor, or 3) mislearned velopharyngeal dysfunction (Liu, 2022).
Speech therapy can treat hypernasality caused by mislearning or by neuromotor disorders (like stroke or TBI).
But structural issues will mostly likely need to be corrected before starting therapy.
Know your patient’s native language as some languages (French, Portuguese, etc.) have nasal vowel sounds that you generally wouldn’t treat (Young, 2023).
Structural Abnormalities
Structural abnormalities that cause hypernasality include:
- Cleft abnormalities, like a cleft palate or palatal fistula.
- Not seen in adults unless they have a condition that wasn’t repaired in childhood
- Trauma to the palate
- Palatopharyngeal disproportion
- Large obstructive tonsils
- Surgery of the palate (e.g., tumor removal, maxillectomy)
- Adenoidectomy
Neurological Impairment
Neurological impairments that can cause or are associated with hypernasality include:
- Stroke (CVA)
- Traumatic brain injury (TBI)
- Parkinson’s disease
- Progressive genetic conditions
- Cerebral palsy
- Motor-programming disorders
Learned Errors
Sometimes hypernasality is present even without structural or neurological impairments. Learned errors include:
- Sensorineural hearing loss that leads to sound errors
- Phoneme-specific nasal emission
- Postoperative nasal emission
- Compensatory misarticulations
(Trost-Cardamone, 1989; Peterson-Falzone, S. J, 2006)
More Popular Articles
When To Refer Out?
Speech therapy won’t help everyone with hypernasality, so it’s important to know when and where to refer your patients.
A specialist can do a full assessment of anatomy and velopharyngeal functioning using special equipment. They can also recommend surgery, prosthetics, and/or medications.
If you suspect that the velum isn’t moving at all, refer out to a specialist before attempting treatment.
But if the velum seems to be moving a bit (the patient can sometimes say non-nasal vowel sounds), give therapy a go—and also refer out to confirm velar movement.
In this case, trial many sessions in a short time frame (e.g. 16 sessions across 4 weeks). If you see improvements, keep going. If not, stop therapy.
Who To Refer To?
Ear Nose Throat Specialist (Otolaryngologist). Refer to an ENT if you see or suspect a structural abnormality.
Neurologist. Refer to a neurologist to help manage an underlying neurological impairment.
Audiologist. Refer to an audiologist if a patient thinks that impaired hearing caused their hypernasal speech.
Prosthodontist. Refer to a prosthodontist if you suspect the patient would benefit from a palatal lift prosthesis. More on that below.
If you have any doubts about your patient’s functioning, don’t hesitate to refer out.
Who Needs A Palatal Lift Prosthesis?
Patients with hypernasality due to structural deficits may benefit from a palatal lift prosthesis. Restoring normal resonance can improve intelligibility.
Your patient may be a good candidate for a palatal lift prosthesis if they have all of the following:
- Velpharyngeal insufficiency with a large and consistent gap between the velum and posterior pharyngeal wall (an instrumental examination can see this)
- Relatively normal articulation
- Relatively intact respiration for speech
- Ability to take care of the prosthesis and remember to use it
- Ability to tolerate it
- Lack of or very minimal gag reflex
- No spasticity
- Unable or unwilling to have surgical correction
What Does Hypernasal Speech Sound Like?
Hypernasal speech can sound as if a person is speaking through their nose (think Bob Dylan or Janice from Friends)
Voiced sounds may sound more like nasal /m, n/ sounds. For example:
- Baby – may sound like ‘many’
- Button – ‘mutton’
- Doodle – ‘noonle’
- Dog – ‘non’
How To Assess Hypernasality
To assess hypernasal speech, complete a resonance assessment.
1. Oral Motor Examination
Observe strength, range of motion, and symmetry
- Mandible (CN V): at rest, open, open with resistance, close, close with resistance, lateralize, protrude, retract
- Lips (CN VII): at rest, protrude, retract, repetitive protrude/retract, puff cheeks, puff cheeks against resistance, sensitivity to touch
- Tongue (CN XII): at rest, protrude out, protrude out with resistance, protrude up, protrude up with resistance, protrude down, protrude down with resistance, lateralize, lateralize with resistance, retract, lick teeth, lick lips
- Velum: at rest (CN IX), prolonged “ah” (CN X), repetitive “ah” (CN X)
- Reflexes (CN IX, X): gag, faucial arches
- Other Observations: dentition, oral mucosa, raise eyebrows, dysarthria, breath support, vocal quality, hearing, cough on command, throat clear on command, maximum phonation time
2. Assess Hypernasality & Nasal Air Emission
Instructions:
- Complete the 3 trials described below.
- Record any errors and observations.
- If the patient has hypernasality, you’ll hear nasal sounds in their repetitions.
- If the patient has nasal air emissions, the tissue will move or the dental mirror will fog up.
Trial 1
Ask the patient to repeat the following sounds and phrases after you:
- ooo
- eee
- sss
- shh
- Papa Bear blows bubbles.
- Give Gary a gift of cookies and cookie.
- Please pay in part for Bob’s burger.
Trial 2
Pinch their nose as they repeat after you:
- ooo
- eee
- sss
- shh
- Papa Bear blows bubbles.
- Give Gary a gift of cookies and cookie.
- Please pay in part for Bob’s burger.
Trial 3
Place a dental mirror under their nose as they repeat after you:
- Peppy puppies play ball.
- People go buy groceries.
- Curiosity killed the cat.
3. Modified Tongue Anchor Test
Ask the patient to: “Stick out your tongue. Keep sticking it out and puff up your cheeks.”
Gently press both of their cheeks. If their velopharyngeal functioning is within normal limits, their cheeks will remain puffed up.
4. Assess Diadochokinetic Rate
“Say the following sound as quickly and clearly as you can for 15 seconds. Repeat 3 times.”
- “Puh puh puh”
- “Tuh tuh tuh”
- “Kuh kuh kuh”
- “Puh tuh kuh”
From the Adult Speech Therapy Evaluation Pack
How To Decrease Hypernasality: Video
Watch a speech-language pathologist model hypernasal speech treatments:
- Labeling
- Nasal vs non-nasals
- Tactile & auditory feedback
- Open mouth posture
- Yawn-sigh technique
6 Hypernasal Speech Treatment Ideas
Awareness is key when treating hypernasality.
Your treatment focus will be helping patients:
- Identify what nasal and non-nasal speech sounds and feels like
- Know when their speech is nasal or non-nasal
- Use strategies to produce less nasal speech
Here are 6 hypernasal speech treatment ideas.
1. Nasal vs. Non-Nasals
Help your patients learn the difference between nasal and non-nasal speech.
- Close your eyes
- Hum the sound “mmmm” continuously
- Gently touch the sides of the bridge of your nose. Feel the vibration
- Say, “ahhhh” continuously
- Gently touch the sides of the bridge of your nose. There should be almost no vibration
- Practice with other nasal and non-nasal sounds
2. Wide Mouth Opening
Have patients exaggerate their mouth movements while speaking. This increases oral activity (instead of nasal activity) and volume.
3. Yawn/Sign Technique
This is meant to lower the back of the tongue and raise the velum to increase oral activity.
- Take in an easy, relaxed breath through your mouth while yawning
- Gently exhale some air, as if you’re sighing
- Yawn in, then sigh out a ‘haaa’ sound
- Yawn in, then sigh out initial /h/ words
- Yawn in, then sigh out /a, e, i, o, u/
- Use this technique while speaking throughout the day
Learn more about the Yawn Sigh Technique.
4. Open Vowels
Say words that have vowels that are ‘open.’ This creates a large space in the back of your mouth.
- Bomb
- Soft
- Moss
- Dot
- Plot
5. Labeling & Negative Practice
Borrowing from Conversation Training Therapy, have patients label and practice both their nasal and non-nasal voices.
This helps them to more easily use their ‘new’ voice in everyday conversation.
- Have your patient describe how their old, hypernasal voice feels and sounds
- Then have them describe how their new, less nasal voice feels and sounds
- Next, have them come up with a label for their new and old voices
- ‘Nasal voice’ vs ‘clear voice’
- Practice both the new and old voices in conversation
Switching between the new and old voices is called ‘negative practice’. Encourage patients to feel and hear the difference as they switch.
Negative practice improves a patient’s sensory awareness of their voice. And it allows them to experience being in control of their voice.
(Gillespie, n.d.)
6. More Hypernasality Tips
Trial each tip to see whether your patient is stimulable for it.
Ask them to read sentences and paragraphs aloud as you monitor their resonance.
- Speak at a different speed (faster or slower)
- Speak in a slightly lower pitch than you’re used to
- Speak slightly louder than you’re used to
- Overarticulate each word
Voice & Resonance PDFs
Visit our shop for printable worksheets & handouts made for speech therapy patients.
References
- Adler, S. (1960). Some Techniques for Treating the Hypernasal Voice. Journal of Speech and Hearing Disorders. https://doi.org/10.1044/jshd.2503.300
- American Speech-Language-Hearing Association. (n.d.). Resonance disorders [Practice portal]. https://www.asha.org/Practice-Portal/Clinical-Topics/Resonance-Disorders/
- Gillespie, A., Gartner-Schmidt, J. (n.d.) Conversation Training Therapy [Online course] Medbridge. https://www.medbridgeeducation.com/courses/details/conversation-training-therapy-jackie-gartner-schmidt-amanda-i-gillespie
- Liu, Y., S. Lee, S. A., & Chen, W. (2022). The Correlation Between Perceptual Ratings and Nasalance Scores in Resonance Disorders: A Systematic Review. Journal of Speech, Language, and Hearing Research. https://doi.org/23814764000300140072
- Peterson-Falzone, S. J., Trost-Cardamone, J. E., Karnell, M. P., & Hardin-Jones, M. A. (2006). The clinician’s guide to treating cleft palate speech. St. Louis, MO: Mosby
- Trost-Cardamone, J. E. (1989). Coming to terms with VPI: A response to Loney and Bloem. Cleft Palate Journal, 26(1), 68–70.
- Young, A., & Spinner, A. (2023). Velopharyngeal Insufficiency. In StatPearls. StatPearls Publishing.