This post covers adult speech therapy for hypernasality, hyponasality, and cul-de-sac resonance.
You’ll find resources on what to assess, step-by-step treatment ideas, and when to refer out.
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Treating Resonance Disorders: Questions to Ask Yourself
Remember that the purpose of speech therapy for resonance disorders is to improve the patient’s quality of life. There’s only so much that speech therapy can do to improve these folks’ quality of life—and that’s okay.
Ask yourself the following questions to guide your decision-making. Then move on to the Resonance Assessment for a step-by-step guide.
1. What is the underlying issue that’s causing the resonance disorder?
- Is it structural?
- Is it neurogenic (stroke, TBI, myasthenia gravis, etc.)?
- Is it due to untreated hearing loss?
- Is it an attention or level-of-consciousness issue?
2. If the cause is structural, who can I refer the patient out to?
3. Are there any resonance strategies I can test for stimuability that may help improve the patient’s quality of life?
- For example, wide mouth opening to increase comprehensibility over the phone.
Resonance Assessment
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 Obervations: dentition, oral mucosa, raise eyebrows, dysarthria, breath support, vocal quality, hearing, cough on command, throat clear on command, maximum phonation time
Hypernasality and Nasal Air Emission
Complete 3 trials.
For trial 1, ask the patient to repeat the sounds and phrases after you. For trial 2, pinch their nose as they repeat. For trial 3, place a dental mirror under their nose as they repeat. Record any errors and observations.
Hyponasality
Ask the patient to repeat after you. If they have hyponasality, the nasal sounds will sound non-nasal. Record any errors and observations.
- May my mom come in?
- Nina has a niece and nephew.
- Each month has a new moon.
- Many mini muffins are messy.
- None knew the nuances of nursing.
Modified Tongue Anchor Test
Ask the patient, “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.
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”
Complete the Motor Speech & Voice Evaluation
Refer to an otolaryngologist as needed to assess and treat any underlying structural issues.
About Nasal Air Emission…
Nasal air emission isn’t a resonance disorder, but it may come up during an assessment.
If your patient has nasal air emissions, consider a referral to an otolaryngologist.
Resonance vs Voice, Dysarthria, or Apraxia
When making your speech therapy diagnosis, consider the difference between resonance, voice, dysarthria, and apraxia. Refer back to your resonance assessment—especially the nose pinch test and nasal vs. non-nasals.
| Resonance Disorder | A resonance disorder is the abnormal shaping of the voice through the vocal tract |
| Voice Disorder | A voice disorder is characterized by abnormal vocal quality related to an issue at the level of the vocal folds |
| Dysarthria | Dysarthria is underlying weakness or coordination of the articulators and can cause reduced intelligibility |
| Apraxia | Apraxia is a motor programming disorder characterized by inconsistent speech errors |
Behavioral Speech Therapy for Hypernasality, Hyponasality, and Cul-de-sac Resonance
Most available speech therapy resources for treating resonance were made for children with congenital craniofacial abnormalities. Their course of treatment is largely surgery plus habilitation (versus rehabilitation).
That said, there are treatment activities that may help adult patients with resonance disorders improve their quality of life.
Keep scrolling for step-by-step treatment ideas.
1. Normal Resonance: Patient Education
If you suspect a resonance disorder, provide patient education on basic anatomy and physiology.
You can ask your patient to look into a hand mirror, say “ahh,” and watch their uvula move up and down. This demonstrates how the velum moves during speech. Educate about how that movement is needed to make nasal and non-nasal sounds.
2. Nasal vs. Non-Nasal: Hypernasality Treatment
PATIENT INSTRUCTIONS
Knowing when you sound hypernasal can help you achieve normal resonance.
- 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.
- If you feel a vibration in your nose while saying “ahhh,” then use your hypernasality tips
3. Hypernasality Tips
PATIENT INSTRUCTIONS
Decrease hypernasality by becoming more aware of it. Learn how to feel and hear when you’re being hypernasal.
Listen To & Label Your Voice. When you hear yourself being hypernasal, then label it. “I sounded hypernasal just now.”
Nasal vs Oral Sounds. Say nasal sounds and oral (non-nasal) sounds, such as “ng” (nasal) and “ah” (oral). Notice how they sound different and feel different when you say them.
Tactile Feedback. Feel the vibrations in the nose when saying nasal sounds, like “nuh” versus non-nasals, like “duh.”
Wide Mouth Opening. Over exaggerate your mouth movements while speaking. This increases oral activity (versus nasal activity) and volume.
Yawn/Sign Technique. This is meant to lower back of tongue and raise the velum (the soft part of the roof of your mouth) to increase oral activity.
- Pretend that you’re going to yawn. Let out a relaxed sigh.
- While you’re sighing, say the following sounds:
- a, e, i, o, u
- Maa, paa, baa, faa, vaa, thaw, naw, taw, daw, raw, saw, law
- Use this technique while speaking throughout the day
5. Open Vowels: Hypernasality Treatment
PATIENT INSTRUCTIONS
Use your hypernasality tips while saying the following vowels. The vowels are “open” which means that you need to create a large space in the back of your mouth to say them.
- Bomb
- Soft
- Moss
- Dot
- Plot
- Rod
- All
- Talk
- Bat
- Hat
4. Cul-de-sac Resonance Tips
PATIENT INSTRUCTIONS
Decrease cul-de-sac resonance by becoming more aware of it. Learn how to feel and hear when your voice isn’t resonating out when it should be.
Yawn-Sign Technique. This is meant to lower back of tongue and raise the velum (the soft, back part of the roof of your mouth).
- Pretend that you’re going to yawn. Let out a relaxed sigh.
- While you’re sighing, say the following sounds:
- a, e, i, o, u
- Maa, paa, baa, faa, vaa, thaw, naw, taw, daw, raw, saw, law
- Use this technique while speaking throughout the day
Open Mouth. Over exaggerate your mouth movements while speaking in order to increase oral activity (versus nasal activity) and volume
Lip Trills. In order to focus your airflow toward the front of your mouth, buzz your lips. Feel the vibration at the front of your face. Try this before speaking so that you remember to project your voice forward.
Treating Resonance Disorders: Head and Neck Cancer
Head and neck cancer includes malignancies of the nasal cavity, paranasal sinuses, oral cavity, pharynx, larynx, and salivary glands.
Resonance disorders caused by structural deficits may be treated with palatal prostheses.
Speech therapy’s role in treating resonance with these patients may include:
- Pre-operative/pre-radiation functional assessment
- Post-operative/post-radiation functional assessment
- Being part of the prosthetics team during the construction and trialing of the prosthesis
- Consulting on prosthetic design, positioning, and/or adjustments to optimize speech and swallowing
- Providing speech retraining with the prosthesis with a focus on nasal resonance, nasal emission, and intelligibility
Resonance Disorders: Referring Out
Many times, the most helpful thing we do for patients with resonance disorders is refer them out to other professionals.
Even if you refer out immediately after the assessment, you may still want to test if your patient is stimulable to the above behavioral resonance tips.
For example, you have a patient who is incomprehensible due solely to their resonance. They speak on the phone a lot and can’t rely on AAC, so you trial the hypernasality tips to see if it can help them more clearly express their wants and needs when talking on the phone.
Referrals for patients with resonance disorders include:
- Surgeon to address structural deficits
- Otolaryngologist for nasal emissions
- Prosthodontist
- Medication management to treat underlying causes of swelling or inflammation in the nasal cavity (allergies, irritants causing hyponasality)
- Audiologist for hearing loss
More Resources
References
- Communication Rehabilitation with People Treated for Oral Cancer by Jeff Searl of Michigan State University
- Head and Neck Cancer by ASHA
- Hutcheson, K.A., Lewin, J.S. (2013). Functional Assessment and Rehabilitation – How to Maximize Outcomes. Otolaryngologic Clinics of North America, 46 (4), 657-670.
- Kreeft, A.M., Molen, L.v.d., Hilgers, F.J. et al. (2009). Speech and swallowing after surgical treatment of advanced oral and oropharyngeal carcinoma: a systematic review of the literature. Eur Arch Otorhinolaryngol, 266, 1687–1698.
- Resonance Disorders by ASHA
- Skelly et al. (1972). Changes in phonatory aspects of glossectomee intelligibility through vocal parameter manipulation. Journal of Speech and Hearing Disorders, 37, 379-389.
- The Adult Speech Therapy Workbook by Chung Hwa Brewer
