Assessing Resonance CC12 Voice/Resonance

Dr. Estes

Cleft overview

• Each year in the United States approximately 3% of all infants are born with a birth difference (Centers for Disease Control and Prevention, 2023).

• One of the most common birth differences is cleft lip with or without palate involvement (National Institute of Dental and Craniofacial Research, 2021).

• Children born with cleft lip and/or palate often require multiple surgeries to reconstruct oral and facial structures to establish improved speech, hearing, and swallowing abilities.

• Cleft lip and cleft palate are among the most common birth differences (Mayo Foundation for Medical Education and Research, 2024).

How do the oral structures develop?

Velopharynx at rest

Competent velopharyngeal function

Incompetent velopharyngeal function

Normal Velopharyngeal Function

Velopharyngeal dysfunction

Comprehensive Assessment of Clefts

• Detailed case history

• Hearing screening

• Oral mech exam

• Resonance - Hypo/hypernasaltiy, cul-de-sac or mixed

• Articulation - usually related to VPD (compensatory articulation)

• Feeding/swallowing - usually related to VPD (nasal regurgitation)

• Language - may be related to syndrome

Diagnostic Interview

• Caregiver or patient fills out questionnaire

  • Form needs to include questions about 

    • Resonance

    • Phonation

    • Articulation

    • Feeding/swallowing 

    • Language

• Clinician asks probing questions to fill in gaps from the questionnaire

Feeding/Swallowing Screening

• Many patients with resonance issues related to VPD also report issues with swallowing

• Nasal regurgitation is commonly reported by patients

• Gagging or globus (feeling of food stuck in the pharynx) is sometimes reported 

• In adults with degenerative disorders, VP function and swallow function may be first signs of the disorder

  • SLP may be first professional to identify the neurodegenerative disease and will need to make further referrals to the neurologist and other professionals

Language Screening

• Children with cleft lip/palate are at increased risk for language delay

  • Best practice is to conduct a language screening annually

  • Formal language screener or language sampling procedures

  • Comprehensive language evaluation should be done for children with

    • Syndromes

    • Hearing loss

    • Neurological issues

    • Other risk factors

• Adults with degenerative diseases often have language and cognitive deficits as well, so it’s always good to screen for these areas

Articulation, Phonation, and Resonance Diagnosis

• Begins with a perceptual assessment

• Perceptual assessment is far more important than instrumental 

• This will determine if instrumental assessments need to be performed - can save time and money

• Survey of 126 SLPs found 99.2% of SLPs on cleft teams use perceptual assessment of VPI (Kummer, 2012) 

• Listen for articulation of speech sounds, phonation, and resonance

Perceptual (Non-instrumental Assessment)

Perceptual assessment: SLP uses clinical judgment to determine if hypernasality or NAE is present, and makes inferences about VP function

• If the perceptual assessment shows no speech abnormality, then it does not matter what the instrumental assessments show 

  • No treatment is warranted

• If there is a speech abnormality - perceptual assessment should determine if it is structural or functional

• Judgment of phonation - determine if full voice evaluation is needed

Perceptual Assessment

• Perceptual assessment is sufficient to diagnose type of resonance disorder (hypernasality, hyponasality, etc.)

• Strategically using different speech samples, such as comparing an all oral passage vs a nasal-loaded passage, can facilitate differential diagnosis for type of nasality

Perceptual Assessments Reveal

Formal Articulation Tests

• Typically only assess word level, some have sentences also

  • Usually neglect other levels of the articulation hierarchy, but SLP can probe 

  • Does not take into account co-articulatory or context effects

  • Often too time-consuming in a medical setting

• GFTA-3

• Arizona-4

• Iowa Pressure Articulation Test

• Templin-Darley Tests of Articulation

• Bzoch Error Pattern Diagnostic Articulation Test

Assessment of Speech Sounds and Intelligibility

• Document phonetic inventory

• Note any phonological or developmental errors (GFTA or DEAP)

• Rate overall intelligibility

• Parent rating scale like the Intelligibility in Context Scale (ICS) and a quality of life measure like the CLEFT-Q

Speech Samples Use

Use of speech samples is highly recommended in this population (adults and children)

Speech Sample Assess

Assess speech production, resonance, and phonation simultaneously

Speech Samples Do not Focus

Do not focus just on word level, but includes isolation, syllables, sentences, and connected speech

Speech Samples Consider

Consider developmental guidelines for speech sound production and syntax in children

• Must determine if it is a developmental error, obligatory error, or a compensatory error caused by the structural/functional deficit

Speech Sample: Phoneme/Syllable Repetition Critical in children with 

• Limited repertoires 

• Little connected speech

• Minimal English

• Poor compliance with standardized tests

Speech Sample: Phoneme/Syllable Repetition Critical in adults with neurogenic disorders

• May be able to produce sounds in isolation/syllables, but not in longer utterances

• May fatigue over time, so beginning of speech sample and end of speech sample may sound different.

Phoneme/Syllable Repetition: 

• Test for hypernasality with vowel prolongation (low vs high vowels)

• Test NAE with high-pressure voiceless consonants (fricatives, affricates, stops)- easier to hear

• Prolong /s/ to assess ability to maintain palate closure

Connected speech:

Places the highest demand on the VP for closing, maintaining closure, and timing for re-opening

Counting:

Have the patient count from 60 to 70

• Small-medium size VP gap- NAE will be audible 

• Large VP gap: there will be no pressure build up for /s/ or the /kst/ blend 

Speech Sample: Sentence Repetition

• Assess articulation placement and resonance at sentence level

• See Table 11-3 for recommended sentences for each phoneme

• This will reveal if there is breakdown with: 

  • Length of utterance

  • Speed of production

  • Specific phonemic contexts

  • Fatigue factor

Calculating Precent Consonants Correct (PCC) can give you an easy baseline measure for progress monitoring

Speech Sample: Counting

• If old enough, have patient count from 60 to 70

• Numbers contain repeated combinations of high vowel /i/ with /s/ and triple blend /kst/

• There is a constant build-up and controlled release of air pressure in the oral cavity

• The VP port should maintain closure from 60 to 67, then VP closure alternates from 67-68-69-70

  • Small-medium sized VP gap - NAE will be audible on this counting task

  • Large VP gap: there will be no pressure build up for /s/ or the /kst/ blend

Speech Sample: Connected Speech

• If the patient is willing to be conversational, this is an important last piece of speech sample

• Connected speech has the highest demands on VP mechanism for closing, maintaining closure, and timing the re-opening

• Both hypernasality and NAE are more apparent in connected speech

• Articulation errors often increase during connected speech

• VPD related to fatigue generally worsens during connected speech

What should an SLP look for in speech sample

• Speech sound production

• Stimulability

• NAE

• Weak consonants

• Short utterance length

• Oral-motor dysfunction

• Type of resonance disorder

• Voice disorder - is there concomitant voice problem?

Speech Sound Production & Stimulability

• All articulation errors in speech sample should be classified as:

  • Developmental Errors: in children only, not adults

    • Do not correct in ST until it is developmentally appropriate

  • Obligatory Distortions: articulation placement and manner is correct, but  abnormal anatomy causes distortions in speech

    • These are not ST issues - they are surgical or dental issues

Speech Sound Production & Stimulability

• Compensatory Errors: patient attempts to produce the sound, making errors in placement or manner due to working around incorrect anatomy and physiology (hence compensatory)

  • To treat compensatory errors, SLP should correct placement and manner

  • May still be obligatory errors until the VP mechanism is surgically corrected

  • Manner is maintained but placement is moved backwards behind the point of cleft or fistula (/?/ for /d/ or /k/ for /t/) 

  • Placement is similar but manner of production is changed, e.g. /n/ for /s/

• Also look for co-articulations (i.e., placement for /t/ along with a glottal stop) 

  • SLP should eliminate glottal stop

• Use diacritics or write words (pharyngeal stop) when completing articulation tests with odd compensatory productions

• Do stimulability testing for each error

• Note any weak consonants: often accompanies hypernasality or NAE

NAE Describe type of nasal emission sound

Low intensity (large VP gap)

Turbulent, rustle sound (small VP gap)

NAE

Nasal grimace (scrunched face) may be present

NAE Observe and Note

which sounds have NAE

consistency of NAE across phonemes

consistency of NAE on short versus long utterances

NAE Utterance Length: have patient count 1-20 

Patient should make it to 15 before taking a breath

Why would a patient with VPD have shorter utterance length?

Oral-Motor Dysfunction

• Hypernasality can be due to neuromotor disorder

  • VP structure may be normal, but neuromotor control may lead to VPI

    • Levator veli palatini: pharyngeal branch of vagus

    • Tensor veli palatini: mandibular branch of trigeminal nerve

    • Pharyngeal constrictors: vagus nerve

• Formal apraxia test

  • Kaufman Speech Praxis Test

  • Dynamic Evaluation of Motor Speech Skill

• Diadochokinesis

Phonation (Voice Diagnostic Screening/Assessment)

• Dysphonia is common in patients with resonance disorders

• CAPE-V (Consensus Auditory-Perceptual Evaluation of Voice)

Phonation (Voice Diagnostic Screening/Assessment) Listen for and rate on severity scale:

• Hoarseness

• Breathiness

• Glottal fry

• Glottal attacks

• Inappropriate pitch level

• Restricted pitch range

• Inappropriate intensity level

Visual Detection

• Mirror Test: hold a small mirror under the nose 

  • See how much mirror fogs up during oral speech sounds (no nasal sounds) 

• Air Paddle: hold a slip of paper under the nose 

  • See it move during production of high-pressure oral speech sounds (no nasal sounds)

• See-scape: a small flexible tube runs from the nostril to a vertical rigid tube

  • As high-pressure oral consonants are produced, NAE will cause the Styrofoam ball in tube to move up and down

Tactile Detection

• Feeling sides of the nose = by palpating the sides of the nose, SLP can sometimes feel the vibrations in the nasal cavity

Auditory Detection

• Nose Pinch Test: patient says an all oral utterance with nose pinched closed, then repeats with  nostrils open 

  • If resonance sounds same both times, VP port functions normally

  • If there is a difference in resonance, VP port is not closing on its own

• Stethoscope: place drum of stethoscope beside nose, or remove drum and place the tube in end of nostril 

  • Can clearly hear hypernasality or NAE

• Listening tube/straw: place one end in nostril and other end near ear to clearly hear hypernasality or NAE

Differential Diagnosis of Cause: VPI vs Fistula vs Artic Diagnosis

1. Consistency of hypernasality/NAE

• Phoneme-specific hypernasality/NAE = mislearning (Only /s/ or high vowels but not low vowels)

• Consistent NAE on all pressure sensitive consonants = VPI

• Intermittent hypernasality = apraxia

• Consistent hypernasality = VP

2. Stimulability testing

• Hypernasality/NAE do not improve with articulation correction = VPI

• Hypernasality/NAE do improve with articulation correction = mislearning

3. Fistula contributions to resonance/NAE

• Plug fistula with chewing gum or a cotton ball covered in Vasoline

• Compare speech with fistula plugged and unplugged

  • Small fistula (less than 5 mm) = no effect b/c airstream is lateral to opening

  • Large fistula will likely produce hypernasality

  • Medium ones are difficult (oral side opening may look larger than actual opening in nasal cavity)

4. Pharyngeal fricative vs lateral /s/ versus NAE with /s/ production (Pharyngeal fricatives can sometimes sound like NAE because of rustly sound in back of pharynx)

• First, place a straw in the nostril to listen for NAE on /s/ attempt

• Then, place straw at midline of the dental arch and listen for airflow on /s/

• Move the straw laterally (at small increments) until SLP hears airflow on /s/ attempt

• Will determine if the airflow is coming medially or laterally through  oral cavity, or through nasal cavity

Small Fistula

Large Fistula

Referrals

Radiology, ENT, neurology, sleep study, etc.

Reccomendations

• ST?

• Frequency? 

Counseling

• Family counseling

• Genetic counseling

Evaluation Report

• No standardized method 

• Should contain all components of a typical evaluation (like the ones in our clinic)

Indirect Instrumental Procedures

1. Nasometry

2. Speech aerodynamics

• Provide objective data regarding the physical correlates of VP function

  • Acoustic output

  • Airflow

  • Air pressure

• Provide scores that can be compared to standardized norms

• Pre- and post-treatment scores can be compared

• Do not directly visualize VP port and other structures

  • Provide data to infer velopharyngeal function

  • Cannot directly observe velopharyngeal functions

Nasometry

• Assesses hyper/hyponasality, NAE, and VP function

• Survey of 126 SLPs found 28.9% use nasometry (Kummer, 2012)

• Only 19% of SLPs who work on cranio teams use nasometry

• Far fewer SLPs who work in other settings use nasometry

• Almost no SLPs in public schools or private clinics use nasometry

• Some universities use it, but usually only if needed for research 

Nasometry

• Separator Plate divides nasal airflow from oral airflow

• Standardized passages are repeated or read aloud

• Measures nasal airflow (N) and oral airflow (O)

  • Calculate nasalance score by dividing N/(N+O) and convert to a percentage 

    • Nasalance = % of nasality in speech

  • Nasalance distance: range between maximum and minimum nasalance

  • Nasalance ratio: minimum nasalance divided by maximum nasalance

Standardized Speech Samples Good for adults, but requires reading, attention span, cognitive ability for complex vocab and syntax (Appendix 14-1 in Kummer)

• Zoo passage: no nasal phonemes

  • Can VP closure be achieved and maintained throughout connected speech? Does not test timing of closure

• Rainbow passage: has 11.5% nasal phonemes (same as normal SAE)

• Nasal Sentences passage: 35% of phonemes are nasal

  • Good for testing hyponasality and nasal obstruction

Standardized Speech Samples For children, recommend using SNAP Test-R (App 14-2 in Kummer)

• Subtest 1: syllable repetition

• Subtest 2: connected speech, using carrier phrases

• Subtest 3: reading child-friendly passages

Nasometry in Treatment

• Provides real-time visual feedback about nasality

• Treatment is only useful if the patient is anatomically and physiologically capable of closing VP mechanism during connected speech

  • Indicated for phoneme-specific learned hypernasality

  • Helpful for post-surgical treatment when patient is learning to use newly corrected anatomy

• SLP sets goal by creating a reference line, and patient works to keep their nasalance line below reference line

• As patient makes progress, reference line can be moved little by little until the patient matches normative score

Speech Aerodynamics

• Measures the airflow and air pressure in the oral and nasal cavity during speech to: 

  • Estimate airway obstruction by measuring nasal airway resistance

  • Calculate the size of the VP opening

• Survey of 126 SLPs found 4.3% use aerodynamics (Kummer, 2012). 

• Used more in research than actual clinical practice

“Orifice Equation”

• Cross-sectional area across the opening of any orifice (including the VP port) can be calculated if you know:

  • Air pressure before the orifice (Point A)

  • Air pressure after the orifice (Point B)

  • Air flow through the orifice

“Orifice Equation” Applied to VP Port Pressure-Flow Technique 

• Insert one pressure transducer into oral cavity (Point A)

• Insert second pressure transducer into nasal cavity (Point B)

• Insert flowmeter into other nostril to measure air flow through VP port

“Orifice Equation” Applied to VP Port Placement of oral transducer must be behind place of artic

• If there is a moving airstream, the open end of the catheter must be perpendicular to flow

• Bilabial stops are usually the easiest placement for the transducer

“Orifice Equation” Applied to VP Port Reported measures can be compared to norms

• Air pressures will be reported as cm H2O

• Air flow will be reported as mL/sec

• VP area will be reported as mm²

“Orifice Equation” Applied to the Nasal Cavity Anterior

Rhinomanometry: nasal resistance and nasal area are measured for both nostrils during quiet breathing 

• Uses tubing placed in each nostril one at a time

“Orifice Equation” Applied to the Nasal Cavity Posterior

Rhinomanometry: nasal resistance and nasal area are measured for each nostril during quiet breathing

• Uses a mask placed over the whole nose

“Orifice Equation” Applied to the Nasal Cavity

Patient scores must be compared to aged norms, as the face grows dramatically throughout childhood changing the average cross-sectional area of the nasal cavity

Direct Instrumental Procedures

• Videofluoroscopic Speech Study (VFSS)

• Video Nasendoscopy Evaluation of Speech (VNES)

• Allow direct visualization of anatomy and physiology during speech and swallowing, but actual assessment is subjective

  • See cause of VPD

  • Determine location of VP gap

  • Determine pattern of VP closure

  • Assess placement of prosthetic

  • Pre- and post-operative assessments

• VFSS was gold standard until 1980s

• 59.3% of SLPs use VNES and 19.2% use VFSS (Kummer, 2012)

Nasal Endoscopy

Direct Instrumental Procedures

• MRI can also be used 

• Disadvantages = too loud for some children, claustrophobic, too expensive

• MRI may eventually replace videofluoroscopy as technology becomes cheaper

VFSS and VNES Speech Sample

• Must tax the velopharyngeal mechanism to induce VPD in mild cases

• Repetition of sounds, syllables, words, and sentences

• Use high-pressure phonemes with high vs low vowels 

  • /pa/ /pa/ /pa/ vs /pi/ /pi/ /pi/

• Use front and back consonants

  • /pa/ /pa/ /pa/ vs /ka/ /ka/ /ka/

• Prolong /s/ sound

• Reading of passages, age permitting

• Counting 60-70

Videofluoroscopy

• With patient supine, use a syringe to inject barium into both nostrils and instruct patient to “sniff it up” 

  • Rotate head to evenly distribute

  • Will coat nasal cavity, nasopharynx, and oropharynx

• Use multiple positions while patient repeats the speech samples (VFSS is 2-D, so multiple views needed to reconstruct 3-D port)

  • Lateral (sagittal) view: visualize velar lift, adenoids, posterior pharyngeal wall, lingual movement

  • Frontal (a-p) view: visualize lateral pharyngeal wall movement and septum

  • Base (bottom-up) view: visualize the circular port from below

  • Towne’s (top-down) view: visualize the circular port from above

  • Oblique view: visualize the port at a 45 angle on the right and the left = used with large adenoids or patients with asymmetrical lateral pharyngeal wall movement

• Have patient swallow first to check VP port function during swallow

• Patient completes the speech sample in each position

• Barium will bubble up on small VP gaps, allowing better visualization for gaps that may not be visible to the eye on screen 

Videofluoroscopy

Video Nasendoscopy

• Minimally invasive direct visualization of nasal, pharyngeal, and laryngeal cavities by inserting a flexible camera scope thru nose

• Used during speech sound production or swallowing to observe function

• Full color, high resolution cameras provide maximum visibility 

• No barium or radiation required

• Can be performed by an SLP independently 

• Much more cost effective that fluoroscopy

• Patient completes speech sample

Documenting instrumental assessment

• Some SLPs use narrative/descriptive format

• Other SLPs use check lists or rating scales

• No standardized format

• Must include cause of resonance disorder, size of VP gap, location of the gap, location of any fistulae, pattern of closure, phoneme-specific differences in VP function or gap size, severity ratings for hypo/hypernasality and NAE